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Saba NF, Wong SJ, Nasti T, McCook-Veal AA, McDonald MW, Stokes WA, Anderson AM, Ekpenyong A, Rupji M, Abousaud M, Rudra S, Bates JE, Remick JS, Joshi NP, Woody NM, Awan M, Geiger JL, Shreenivas A, Samsa J, Ward MC, Schmitt NC, Patel MR, Higgins KA, Teng Y, Steuer CE, Shin DM, Liu Y, Ahmed R, Koyfman SA. Intensity-Modulated Reirradiation Therapy With Nivolumab in Recurrent or Second Primary Head and Neck Squamous Cell Carcinoma: A Nonrandomized Controlled Trial. JAMA Oncol 2024:2819049. [PMID: 38780927 DOI: 10.1001/jamaoncol.2024.1143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Importance Intensity-modulated radiation therapy (IMRT) reirradiation of nonmetastatic recurrent or second primary head and neck squamous cell carcinoma (HNSCC) results in poor progression-free survival (PFS) and overall survival (OS). Objective To investigate the tolerability, PFS, OS, and patient-reported outcomes with nivolumab (approved standard of care for patients with HNSCC) during and after IMRT reirradiation. Design, Setting, and Participants In this multicenter nonrandomized phase 2 single-arm trial, the treatment outcomes of patients with recurrent or second primary HNSCC who satisfied recursive partitioning analysis class 1 and 2 definitions were evaluated. Between July 11, 2018, and August 12, 2021, 62 patients were consented and screened. Data were evaluated between June and December 2023. Intervention Sixty- to 66-Gy IMRT in 30 to 33 daily fractions over 6 to 6.5 weeks with nivolumab, 240 mg, intravenously 2 weeks prior and every 2 weeks for 5 cycles during IMRT, then nivolumab, 480 mg, intravenously every 4 weeks for a total nivolumab duration of 52 weeks. Main Outcomes and Measures The primary end point was PFS. Secondary end points included OS, incidence, and types of toxic effects, including long-term treatment-related toxic effects, patient-reported outcomes, and correlatives of tissue and blood biomarkers. Results A total of 62 patients were screened, and 51 were evaluable (median [range] age was 62 [56-67] years; 42 [82%] were male; 6 [12%] had p16+ disease; 38 [75%] had salvage surgery; and 36 [71%.] had neck dissection). With a median follow-up of 24.5 months (95% CI, 19.0-25.0), the estimated 1-year PFS was 61.7% (95% CI, 49.2%-77.4%), rejecting the null hypothesis of 1-year PFS rate of less than 43.8% with 1-arm log-rank test P = .002 within a 1-year timeframe. The most common treatment-related grade 3 or higher adverse event (6 [12%]) was lymphopenia with 2 patients (4%) and 1 patient each (2%) exhibiting colitis, diarrhea, myositis, nausea, mucositis, and myasthenia gravis. Functional Assessment of Cancer Therapy-General and Functional Assessment of Cancer Therapy-Head and Neck Questionnaire quality of life scores remained stable and consistent across all time points. A hypothesis-generating trend favoring worsening PFS and OS in patients with an increase in blood PD1+, KI67+, and CD4+ T cells was observed. Conclusions and Relevance This multicenter nonrandomized phase 2 trial of IMRT reirradiation therapy and nivolumab suggested a promising improvement in PFS over historical controls. The treatment was well tolerated and deserves further evaluation. Trial Registration ClinicalTrials.gov Identifier: NCT03521570.
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Affiliation(s)
- Nabil F Saba
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Stuart J Wong
- Department of Medicine, Medical College of Wisconsin, Pleasant Prairie
| | - Tahseen Nasti
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- The Emory Vaccine Center, Emory University, Atlanta, Georgia
| | - Ashley Alesia McCook-Veal
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Mark W McDonald
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - William A Stokes
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | | | - Asari Ekpenyong
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Manali Rupji
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Marin Abousaud
- Astellas Pharma Global Development Inc, Northbrook, Illinois
| | - Soumon Rudra
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - James E Bates
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Jill S Remick
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Nikhil P Joshi
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio
| | - Neil M Woody
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio
| | - Musaddiq Awan
- Department of Medicine, Medical College of Wisconsin, Pleasant Prairie
| | - Jessica L Geiger
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio
| | - Aditya Shreenivas
- Department of Medicine, Medical College of Wisconsin, Pleasant Prairie
| | - Julia Samsa
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio
| | | | - Nicole C Schmitt
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Otolaryngology, Emory University, Atlanta, Georgia
| | - Mihir R Patel
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Otolaryngology, Emory University, Atlanta, Georgia
| | - Kristin A Higgins
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Yong Teng
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Conor E Steuer
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Dong M Shin
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
- Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Yuan Liu
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rafi Ahmed
- Winship Cancer Institute, Emory University, Atlanta, Georgia
- The Emory Vaccine Center, Emory University, Atlanta, Georgia
| | - Shlomo A Koyfman
- Department of Radiation Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio
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Anderson JL, Schreibmann E, Bates JE, Rudra S, Hall B, Neunuebel A, Remick JS, Stokes WA, McDonald MW. Photon vs. Proton Radiotherapy in the Definitive Treatment of Nasopharyngeal Cancer: Single Institution Experience. Int J Radiat Oncol Biol Phys 2023; 117:e562. [PMID: 37785723 DOI: 10.1016/j.ijrobp.2023.06.1882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Definitive therapy for nasopharyngeal cancer includes chemotherapy and radiation (RT). Common toxicities such as xerostomia, mucositis, and hearing loss are correlated with the RT dose delivered to associated organs at risk. We hypothesized that compared to our historical experience with IMRT, the implementation of proton therapy (PT) would reduce radiation dose to organs at risks without compromising oncologic outcomes. MATERIALS/METHODS A retrospective review of all non-metastatic stage II-IV nasopharyngeal carcinoma (SCC, lymphoepithelioma, undifferentiated carcinomas) treated with definitive therapy at our institution from 2012-2022. Disease parameters and the mean dose to organs at risk were evaluated. Statistical comparison was made with the chi square test for categorical and Wilcoxon rank sum test for continuous variables. The Kaplan-Meier method was used to estimate overall survival (OS) and progression-free survival (PFS), using a log-rank test to compare IMRT and PT. PFS was defined as the time from the start of treatment to the first of either disease progression, relapse or death from any cause. PT was delivered with pencil-beam scanning in all patients. IMRT included multi-field treatment and volumetric-modulated arc therapy. RESULTS A total of 80 patients were included in analyses: 48 treated with IMRT and 32 with PT. Comparing IMRT to PT cohorts, there was no difference in the median age of patients (51 vs 55 years, p = 0.73), nor the distribution by T stage (p = 0.57) or N stage (p = 0.34) or in the percentage of patients with ECOG 2/3 performance status at presentation (p = 0.11). All but one patient received concurrent systemic therapy and there was no difference in the use of concurrent cisplatin between cohorts (83% vs 78%, p = 0.57). The most common non-cisplatin concurrent regimen was weekly carboplatin and paclitaxel. Induction chemotherapy was more commonly used in patients treated with PT (10.4% vs 25%, p = 0.04) while there was no difference in the use of adjuvant chemotherapy (10.4% vs 9.4%, p = 0.88). Among 42 cases initiating treatment since the opening of our proton center, 32 (76%) have received PT. Comparing IMRT and PT dosimetry, patients treated with PT received significantly lower mean dose to the better spared parotid gland (32.8 vs 25.7 Gy, p = 0.001), lesser spared parotid gland (35.5 vs 31.1 Gy, p = 0.047), better spared cochlea (31.5 vs 25.5 Gy, p = 0.004), lesser spared cochlea (41.8 vs 33.2 Gy, p = 0.004), larynx (44.5 vs 21.7 Gy, p<0.001), and oral cavity (42.6 vs 17.0 Gy, p<0.001). After a median follow-up time of 30 months (45 mos IMRT, 23 mos PT) the estimated 2-year PFS was 63.9% with IMRT and 90.3% with PT (p = 0.047). The estimate of 2-year overall survival was 86.8% with IMRT and 96.8% with PT (p = 0.17). CONCLUSION Comparing patients by radiation treatment modality, PT was associated with a statistically significant reduction in mean radiation dose to the parotid glands, cochlea, larynx, and oral cavity with excellent initial oncologic outcomes.
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Affiliation(s)
- J L Anderson
- Winship Cancer Institute of Emory University, Department of Radiation Oncology, Atlanta, GA
| | - E Schreibmann
- Winship Cancer Institute of Emory University, Department of Radiation Oncology, Atlanta, GA
| | - J E Bates
- Winship Cancer Institute of Emory University, Department of Radiation Oncology, Atlanta, GA
| | - S Rudra
- Winship Cancer Institute of Emory University, Department of Radiation Oncology, Atlanta, GA
| | - B Hall
- Emory University School of Medicine, Atlanta, GA
| | - A Neunuebel
- Emory University School of Medicine, Atlanta, GA
| | - J S Remick
- Winship Cancer Institute of Emory University, Department of Radiation Oncology, Atlanta, GA
| | - W A Stokes
- Winship Cancer Institute of Emory University, Department of Radiation Oncology, Atlanta, GA
| | - M W McDonald
- Winship Cancer Institute of Emory University, Department of Radiation Oncology, Atlanta, GA
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Chang CW, Bohannon D, Tian Z, Wang Y, McDonald MW, Yu DS, Liu T, Zhou J, Yang X. Estimating Potential Benefits of Online Adaptive Proton Therapy for Head-and-Neck Cancer: A Retrospective Study. Int J Radiat Oncol Biol Phys 2023; 117:e649. [PMID: 37785928 DOI: 10.1016/j.ijrobp.2023.06.2069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Proton therapy is highly sensitive to anatomical changes and setup variations in head-and-neck (HN) treatments. To address this issue, proton centers often acquire patient CT images weekly to monitor patient anatomical changes during the treatment course and perform offline plan adaptation when needed. However, offline adaptation cannot fully account for daily setup variations or the anatomical changes occurring with high frequency. There are a few groups endeavoring to develop advanced technologies to enable online adaptive proton therapy (APT). However, the necessity of online APT remains controversial, as it is unknown that whether online APT will significantly improve treatment quality and outcomes compared to offline APT. The purpose of this study is to estimate the clinical potential of online APT in the management of HN cancers in relation to the current offline APT. MATERIALS/METHODS Our retrospective study was conducted with four HN patients (35 fractions per patient), who had been treated with intensity modulated proton therapy and had offline adaptation once or twice during their treatment courses. Synthetic CT (sCT) images were generated from 140 daily CBCT images for us to recalculate the dose of the treatment plan in patient's actual treatment anatomy for each treatment fraction and adapt the plan when warranted. These adaptations were assumed to be performed online before treatment delivery to mimic an online APT course. Accumulative doses were calculated for both courses using the CBCT-based sCT images of every fraction for us to compare the target coverage, organ at risk (OAR) sparing, tumor control probability (TCP) and normal tissue complication probability (NTCP). An in-house script was developed to semi-automate this process in a commercial treatment planning system to facilitate our study. RESULTS All patients would benefit from online APT to different extents. For the first patient, with OAR doses comparable to the actual offline course, the retrospective online APT course improved dose coverages of the three CTVs from 95.2%, 98.64% and 89.53% to 98.88%, 99.81%, 98.97%, which would lead to a 4.52% improvement in TCP. Similarly, online APT would yield a 2.66% improvement in TCP for the second patient. For the third patient, with comparable CTV dose coverages, the mean doses of right parotid and oral cavity were decreased from 29.52 Gy relative biological effectiveness (RBE) and 41.89 Gy RBE to 22.16 Gy RBE and 34.61 Gy RBE, leading to a reduce of 1.67% and 3.40% in NTCP. The mean dose of right parotid was decreased from 21.71 Gy RBE to 19.37 Gy RBE for the last patient, leading to a reduce of 0.73% in NTCP. CONCLUSION Our results showed that online APT could better maintain the treatment plan quality than offline APT for all the four patients, despite their significant anatomical changes. Future investigation will focus on collecting more patient data to obtain statistically significant results and help identify the patients to whom the online APT will be of most benefit.
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Affiliation(s)
| | - D Bohannon
- Department of Medical Physics, Georgia Institute of Technology, Atlanta, GA
| | | | - Y Wang
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - M W McDonald
- Winship Cancer Institute of Emory University, Department of Radiation Oncology, Atlanta, GA
| | - D S Yu
- Emory University, Atlanta, GA
| | - T Liu
- Icahn School of Medicine at Mount Sinai, New York, NY
| | - J Zhou
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - X Yang
- Department of Radiation Oncology, Emory University, Atlanta, GA
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Bohannon D, Janopaul-Naylor J, Rudra S, Yang X, Chang CW, Wang Y, Ma C, Patel SA, McDonald MW, Zhou J. Prediction of plan adaptation in head and neck cancer proton therapy using clinical, radiographic, and dosimetric features. Acta Oncol 2023:1-8. [PMID: 37335043 DOI: 10.1080/0284186x.2023.2224050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
PURPOSE Because proton head and neck (HN) treatments are sensitive to anatomical changes, plan adaptation (re-plan) during the treatment course is needed for a significant portion of patients. We aim to predict re-plan at plan review stage for HN proton therapy with a neural network (NN) model trained with patients' dosimetric and clinical features. The model can serve as a valuable tool for planners to assess the probability of needing to revise the current plan. METHODS AND MATERIALS Mean beam dose heterogeneity index (BHI), defined as the ratio of the maximum beam dose to the prescription dose, plan robustness features (clinical target volume (CTV), V100 changes, and V100 > 95% passing rates in 21 robust evaluation scenarios), as well as clinical features (e.g., age, tumor site, and surgery/chemotherapy status) were gathered from 171 patients treated at our proton center in 2020, with a median age of 64 and stages from I-IVc across 13 HN sites. Statistical analyses of dosimetric parameters and clinical features were conducted between re-plan and no-replan groups. A NN was trained and tested using these features. Receiver operating characteristic (ROC) analysis was conducted to evaluate the performance of the prediction model. A sensitivity analysis was done to determine feature importance. RESULTS Mean BHI in the re-plan group was significantly higher than the no-replan group (p < .01). Tumor site (p < .01), chemotherapy status (p < .01), and surgery status (p < .01) were significantly correlated to re-plan. The model had sensitivities/specificities of 75.0%/77.4%, respectively, and an area under the ROC curve of .855. CONCLUSION There are several dosimetric and clinical features that correlate to re-plans, and NNs trained with these features can be used to predict HN re-plans, which can be used to reduce re-plan rate by improving plan quality.
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Affiliation(s)
- D Bohannon
- Department of Nuclear and Radiological Engineering, Georgia institute of Technology, Atlanta, GA, USA
| | - J Janopaul-Naylor
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - S Rudra
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - X Yang
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - C W Chang
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Y Wang
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - C Ma
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - S A Patel
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - M W McDonald
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - J Zhou
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
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McDonald MW, Bates JE, McCall NS, Goyal S, Liu Y, Rudra S, Remick JS, Tian S, El-Deiry MW, Saba NF, Stokes WA, Swinney E. Insurance Authorization and Access to Proton Therapy for Patients With Head and Neck Cancers. Int J Radiat Oncol Biol Phys 2023; 116:404-412. [PMID: 36889515 DOI: 10.1016/j.ijrobp.2023.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 02/17/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
PURPOSE We evaluated our institutional experience to assess potential racial inequities in insurance coverage for proton therapy in patients with head and neck (HN) cancer. METHODS AND MATERIALS We examined the demographics of 1519 patients with HN cancer seen in consultation at our HN multidisciplinary clinic (HN MDC) and 805 patients for whom a proton insurance authorization was sought (PAS) from January 2020 to June 2022. The prospects for proton therapy insurance authorization were prospectively noted based on each patient's ICD-10 (International Classification of Diseases, 10th Revision) diagnosis code and their specific insurance plan. Proton-unfavorable (PU) insurance were those plans whose policy describes proton beam therapy as "experimental" or "not medically necessary" for the given diagnosis. RESULTS For patients seen in our HN MDC, Black, Indigenous, and people of color (BIPOC) were significantly more likely to have PU insurance than non-Hispanic White (NHW) patients (24.9% vs 18.4%, P = .005). In multivariable analysis including race, average income of residence ZIP code, and Medicare eligibility age, BIPOC patients had an odds ratio of 1.25 for PU insurance (P = .041). In the PAS cohort, while there was no difference in the percentage of patients receiving insurance approval for proton therapy between NHW and BIPOC populations (88% vs 88.2%, P = .80), for patients with PU insurance, the median time to determination was significantly longer (median, 15.5 days), and the median time to start any radiation of any modality was longer (46 vs 35 days, P = .08). Compared with NHW patients, the median time from consultation to start of radiation therapy was longer for BIPOC patients (37 vs 43 days, P = .01). CONCLUSIONS BIPOC patients were significantly more likely to have insurance plans unfavorable to proton therapy coverage. These PU insurance plans were associated with a longer median time to determination, a lower approval rate for proton therapy, and a longer time to start radiation of any modality.
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Affiliation(s)
- Mark W McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia.
| | - James E Bates
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Neal S McCall
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Subir Goyal
- Biostatistics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Yuan Liu
- Biostatistics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia; Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Soumon Rudra
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Jill S Remick
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Mark W El-Deiry
- Department of Otolaryngology Head and Neck Surgery, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Nabil F Saba
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - William A Stokes
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Erica Swinney
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
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Janopaul-Naylor JR, Rupji M, Tobillo RA, Lorenz JW, Switchenko JM, Tian S, Kaka AS, Qian DC, Schlafstein AJ, Steuer CE, Remick JS, Rudra S, McDonald MW, Saba NF, Stokes WA, Patel MR, Bates JE. Ninety-day mortality following transoral robotic surgery or radiation at Commission on Cancer-accredited facilities. Head Neck 2023; 45:658-663. [PMID: 36549012 PMCID: PMC9898134 DOI: 10.1002/hed.27282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Postoperative mortality for oropharynx squamous cell carcinoma (OPSCC) with transoral robotic surgery (TORS) varies from 0.2% to 6.5% on trials; the real-world rate is unknown. METHODS NCDB study from 2010 to 2017 for patients with cT1-2N0-2M0 OPSCC with Charleson-Deyo score 0-1. Ninety-day mortality assessed from start and end of treatment at Commission on Cancer-accredited facilities. RESULTS 3639 patients were treated with TORS and 1937 with radiotherapy. TORS cohort had more women and higher income, was younger, more often treated at academic centers, and more likely to have private insurance (all p < 0.05). Ninety-day mortality was 1.3% with TORS and 0.7% or 1.4% from start or end of radiotherapy, respectively. From end of therapy, there was no significant difference on MVA between treatment modality. CONCLUSIONS There is minimal difference between 90-day mortality in patients treated with TORS or radiotherapy for early-stage OPSCC. While overall rates are low, for patients with expectation of cure, work is needed to identify optimal treatment.
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Affiliation(s)
- James R. Janopaul-Naylor
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Manali Rupji
- Biostatistics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Rachel A. Tobillo
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Joshua W. Lorenz
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Jeffrey M. Switchenko
- Biostatistics Shared Resource, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health at Emory University, Atlanta, Georgia, USA
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Azeem S. Kaka
- Department of Otolaryngology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - David C. Qian
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Ashley J. Schlafstein
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Conor E. Steuer
- Department of Hematology and Medical Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Jill S. Remick
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Soumon Rudra
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Mark W. McDonald
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Nabil F. Saba
- Department of Otolaryngology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
- Department of Hematology and Medical Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - William A. Stokes
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - Mihir R. Patel
- Department of Otolaryngology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
| | - James E. Bates
- Department of Radiation Oncology, Winship Cancer Institute at Emory University, Atlanta, Georgia, USA
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Janopaul-Naylor JR, Cao Y, McCall NS, Switchenko JM, Tian S, Chen H, Stokes WA, Kesarwala AH, McDonald MW, Shelton JW, Bradley JD, Higgins KA. Definitive intensity modulated proton re-irradiation for lung cancer in the immunotherapy era. Front Oncol 2023; 12:1074675. [PMID: 36733369 PMCID: PMC9888533 DOI: 10.3389/fonc.2022.1074675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 12/29/2022] [Indexed: 01/18/2023] Open
Abstract
Introduction As immunotherapy has improved distant metastasis-free survival (DMFS) in Non-Small Cell Lung Cancer (NSCLC), isolated locoregional recurrences have increased. However, management of locoregional recurrences can be challenging. We report our institutional experience with definitive intent re-irradiation using Intensity Modulated Proton Therapy (IMPT). Method Retrospective cohort study of recurrent or second primary NSCLC or LS-SCLC treated with IMPT. Kaplan-Meier method and log-rank test were used for time-to-event analyses. Results 22 patients were treated from 2019 to 2021. After first course of radiation (median 60 Gy, range 45-70 Gy), 45% received adjuvant immunotherapy. IMPT re-irradiation began a median of 28.2 months (8.8-172.9 months) after initial radiotherapy. The median IMPT dose was 60 GyE (44-60 GyE). 36% received concurrent chemotherapy with IMPT and 18% received immunotherapy after IMPT. The median patient's IMPT lung mean dose was 5.3 GyE (0.9-13.9 GyE) and 5 patients had cumulative esophagus max dose >100 GyE with 1-year overall survival (OS) 68%, 1-year local control 80%, 1-year progression free survival 45%, and 1-year DMFS 60%. Higher IMPT (HR 1.4; 95% CI 1.1-1.7, p=0.01) and initial radiotherapy mean lung doses (HR 1.3; 95% CI 1.0-1.6, p=0.04) were associated with worse OS. Two patients developed Grade 3 pneumonitis or dermatitis, one patient developed Grade 2 pneumonitis, and seven patients developed Grade 1 toxicity. There were no Grade 4 or 5 toxicities. Discussion Definitive IMPT re-irradiation for lung cancer can prolong disease control with limited toxicity, particularly in the immunotherapy era.
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Affiliation(s)
- James R. Janopaul-Naylor
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Yichun Cao
- Biostatistics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Neal S. McCall
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Jeffrey M. Switchenko
- Biostatistics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, United States
- Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA, United States
| | - Sibo Tian
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Haijian Chen
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - William A. Stokes
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Aparna H. Kesarwala
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Mark W. McDonald
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Joseph W. Shelton
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Jeffrey D. Bradley
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
| | - Kristin A. Higgins
- Winship Cancer Institute, Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA, United States
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8
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Zhou J, Kang M, Wang Y, Higgins KA, Simone CB, Patel P, McDonald MW, Lin L, Bohannon D. Proton liver stereotactic body radiation therapy: Treatment techniques and dosimetry feasibility from a single institution. J Radiosurg SBRT 2023; 9:33-42. [PMID: 38029011 PMCID: PMC10681147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 08/22/2023] [Indexed: 12/01/2023]
Abstract
Purpose To assess the resulting dosimetry characteristics of simulation and planning techniques for proton stereotactic body radiation therapy (SBRT) of primary and secondary liver tumors. Methods Consecutive patients treated under volumetric daily image guidance with liver proton SBRT between September 2019 and March 2022 at Emory Proton Therapy Center were included in this study. Prescriptions ranged from 40 Gy to 60 Gy in 3- or 5-fraction regimens, and motion management techniques were used when target motion exceeded 5 mm. 4D robust optimization was used when necessary. Dosimetry evaluation was conducted for ITV V100, D99, Dmax, and liver-ITV mean dose and D700cc. Statistical analysis was performed using independent-samples Mann-Whitney U tests. Results Thirty-six tumors from 29 patients were treated. Proton therapy for primary and secondary liver tumors using motion management techniques and robust optimization resulted in high target coverage and low doses to critical organs. The median ITV V100% was 100.0%, and the median ITV D99% was 111.3%. The median liver-ITV mean dose and D700cc were 499 cGy and 5.7 cGy, respectively. The median conformity index (CI) was 1.03, and the median R50 was 2.56. Except for ITV D99% (primary 118.1% vs. secondary 107.2%, p = 0.005), there were no significant differences in age, ITV volume, ITV V100%, ITV maximum dose, liver-ITV mean dose, or D700cc between primary and secondary tumor groups. Conclusion The study demonstrated that proton therapy with motion management techniques and robust optimization achieves excellent target coverage with low normal liver doses for primary and secondary liver tumors. The results showed high target coverage, high conformality, and low doses to the liver.
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Affiliation(s)
- Jun Zhou
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | | | - Yinan Wang
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | | | | | - Pretesh Patel
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Mark W. McDonald
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Liyong Lin
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
| | - Duncan Bohannon
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA
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9
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Pfister NT, Cao Y, Schlafstein AJ, Switchenko J, Patel PR, McDonald MW, Tian S, Landry JC, Alese OB, Gunthel C, Lin JY. Factors Affecting Clinical Outcomes Among Patients Infected With HIV and Anal Cancer Treated With Modern Definitive Chemotherapy and Radiation Therapy. Adv Radiat Oncol 2022; 8:101155. [PMID: 36845623 PMCID: PMC9943777 DOI: 10.1016/j.adro.2022.101155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/09/2022] [Indexed: 12/27/2022] Open
Abstract
Purpose Anal cancer affects a disproportionate percentage of persons infected with human immunodeficiency virus (HIV). We analyzed a cohort of patients with HIV and anal cancer who received modern radiation therapy (RT) and concurrent chemotherapy to assess whether certain factors are associated with poor oncologic outcomes. Patients and Methods We performed a retrospective chart review of 75 consecutive patients with HIV infection and anal cancer who received definitive chemotherapy and RT from 2008 to 2018 at a single academic institution. Local recurrence, overall survival, changes in CD4 counts, and toxicities were investigated. Results Most patients were male (92%) with large representation from Black patients (77%). The median pretreatment CD4 count was 280 cells/mm3, which was persistently lower at 6 and 12 months' posttreatment, 87 cells/mm3 and 182 cells/mm3, respectively (P < .001). Most (92%) patients received intensity modulated RT; median dose was 54 Gy (Range, 46.8-59.4 Gy). At a median follow-up 5.4 years (Range, 4.37-6.21 years), 20 (27%) patients had disease recurrence and 10 (13%) had isolated local failures. Nine patients died due to progressive disease. In multivariable analysis, clinically node negative involvement was significantly associated with better overall survival (hazard ratio, 0.39; 95% confidence interval, 0.16-1.00, P = .049). Acute grade 2 and 3 skin toxicities were common, at 83% and 19%, respectively. Acute grade 2 and 3 gastrointestinal toxicities were 9% and 3%, respectively. Acute grade 3 hematologic toxicity was 20%, and one grade 5 toxicity was reported. Several late grade 3 toxicities persisted: gastrointestinal (24%), skin (17%), and hematologic (6%). Two late grade 5 toxicities were noted. Conclusions Most patients with HIV and anal cancer did not experience local recurrence; however, acute and late toxicities were common. CD4 counts at 6 and 12 months' posttreatment remained lower than pretreatment CD4 counts. Further attention to treatment of the HIV-infected population is needed.
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Affiliation(s)
- Neil T. Pfister
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Yichun Cao
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Ashely J. Schlafstein
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Jeffrey Switchenko
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Pretesh R. Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Mark W. McDonald
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Jerome C. Landry
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Olatunji B. Alese
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Clifford Gunthel
- Department of Medicine – Infectious Diseases Program, Emory University School of Medicine, Atlanta, Georgia
| | - Jolinta Y. Lin
- Department of Radiation Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia,Corresponding author: Jolinta Y. Lin, MD
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10
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Chang C, Charyyev S, Harms J, Slopsema R, Wolf J, Refai D, Yoon T, McDonald MW, Bradley JD, Leng S, Zhou J, Yang X, Lin L. A component method to delineate surgical spine implants for proton Monte Carlo dose calculation. J Appl Clin Med Phys 2022; 24:e13800. [PMID: 36210177 PMCID: PMC9859997 DOI: 10.1002/acm2.13800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/09/2022] [Accepted: 09/22/2022] [Indexed: 01/26/2023] Open
Abstract
PURPOSE Metallic implants have been correlated to local control failure for spinal sarcoma and chordoma patients due to the uncertainty of implant delineation from computed tomography (CT). Such uncertainty can compromise the proton Monte Carlo dose calculation (MCDC) accuracy. A component method is proposed to determine the dimension and volume of the implants from CT images. METHODS The proposed component method leverages the knowledge of surgical implants from medical supply vendors to predefine accurate contours for each implant component, including tulips, screw bodies, lockers, and rods. A retrospective patient study was conducted to demonstrate the feasibility of the method. The reference implant materials and samples were collected from patient medical records and vendors, Medtronic and NuVasive. Additional CT images with extensive features, such as extended Hounsfield units and various reconstruction diameters, were used to quantify the uncertainty of implant contours. RESULTS For in vivo patient implant estimation, the reference and the component method differences were 0.35, 0.17, and 0.04 cm3 for tulips, screw bodies, and rods, respectively. The discrepancies by a conventional threshold method were 5.46, 0.76, and 0.05 cm3 , respectively. The mischaracterization of implant materials and dimensions can underdose the clinical target volume coverage by 20 cm3 for a patient with eight lumbar implants. The tulip dominates the dosimetry uncertainty as it can be made from titanium or cobalt-chromium alloys by different vendors. CONCLUSIONS A component method was developed and demonstrated using phantom and patient studies with implants. The proposed method provides more accurate implant characterization for proton MCDC and can potentially enhance the treatment quality for proton therapy. The current proof-of-concept study is limited to the implant characterization for lumbar spine. Future investigations could be extended to cervical spine and dental implants for head-and-neck patients where tight margins are required to spare organs at risk.
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Affiliation(s)
- Chih‐Wei Chang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Serdar Charyyev
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Joseph Harms
- Department of Radiation OncologyUniversity of AlabamaBirminghamAlabamaUSA
| | - Roelf Slopsema
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Jonathan Wolf
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Daniel Refai
- Department of NeurosurgeryEmory UniversityAtlantaGeorgiaUSA
| | - Tim Yoon
- Department of OrthopaedicsEmory UniversityAtlantaGeorgiaUSA
| | - Mark W. McDonald
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Jeffrey D. Bradley
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Shuai Leng
- Department of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA,Department of Biomedical InformaticsEmory UniversityAtlantaGeorgiaUSA
| | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer InstituteEmory UniversityAtlantaGeorgiaUSA
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11
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Stanforth A, Lin L, Beitler JJ, Janopaul-Naylor JR, Chang CW, Press RH, Patel SA, Zhao J, Eaton B, Schreibmann EE, Jung J, Bohannon D, Liu T, Yang X, McDonald MW, Zhou J. Onboard cone-beam CT-based replan evaluation for head and neck proton therapy. J Appl Clin Med Phys 2022; 23:e13550. [PMID: 35128788 PMCID: PMC9121026 DOI: 10.1002/acm2.13550] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 12/08/2021] [Accepted: 01/20/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Quality assurance computed tomography (QACT) is the current clinical practice in proton therapy to evaluate the needs for replan. QACT could falsely indicate replan because of setup issues that would be solved on the treatment machine. Deforming the treatment planning CT (TPCT) to the pretreatment CBCT may eliminate this issue. We investigated the performance of replan evaluation based on deformed TPCT (TPCTdir) for proton head and neck (H&N) therapy. Methods and materials Twenty‐eight H&N datasets along with pretreatment CBCT and QACT were used to validate the method. The changes in body volume were analyzed between the no‐replan and replan groups. The dose on the TPCTdir, the deformed QACT (QACTdir), and the QACT were calculated by applying the clinical plans to these image sets. Dosimetric parameters’ changes, including ΔD95, ΔDmean, and ΔD1 for the clinical target volumes (CTVs) were calculated. Receiver operating characteristic curves for replan evaluation based on ΔD95 on QACT and TPCTdir were calculated, using ΔD95 on QACTdir as the reference. A threshold for replan based on ΔD95 on TPCTdir is proposed. The specificities for the proposed method were calculated. Results The changes in the body contour were 95.8 ± 83.8 cc versus 305.0 ± 235.0 cc (p < 0.01) for the no‐replan and replan groups, respectively. The ΔD95, ΔDmean, and ΔD1 are all comparable for all the evaluations. The differences between TPCTdir and QACTdir evaluations were 0.30% ± 0.86%, 0.00 ± 0.22 Gy, and −0.17 ± 0.61 Gy for CTV ΔD95, ΔDmean, and ΔD1, respectively. The corresponding differences between the QACT and QACTdir were 0.12% ± 1.1%, 0.02 ± 0.32 Gy, and −0.01 ± 0.71 Gy. CTV ΔD95 > 2.6% in TPCTdir was chosen as the threshold to trigger QACT/replan. The corresponding specificity was 94% and 98% for the clinical practice and the proposed method, respectively. Conclusions The replan evaluation based on TPCTdir provides better specificity than that based on the QACT.
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Affiliation(s)
- Alexander Stanforth
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jonathan J Beitler
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - James R Janopaul-Naylor
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Chih-Wei Chang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Robert H Press
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,New York Proton Center, New York, New York, USA
| | - Sagar A Patel
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jennifer Zhao
- Department of Pre-Medicine, Cornell University, New York, New York, USA
| | - Bree Eaton
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Eduard E Schreibmann
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - James Jung
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Duncan Bohannon
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA.,Medical Physics Program, Georgia institute of Technology, Atlanta, Georgia, USA
| | - Tian Liu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Mark W McDonald
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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12
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Dhere VR, Escott CE, Tian S, Switchenko JM, Bell JP, Stokes WA, McDonald MW, Magliocca KR, Boyce BJ, Kaka AS, Steuer CE, Saba NF, Shin DM, Xiao C, Patel MR, Beitler JJ. The omission of intentional primary site radiation following transoral robotic surgery in 59 patients: No local-regional failures. Head Neck 2022; 44:382-390. [PMID: 34850994 PMCID: PMC8766901 DOI: 10.1002/hed.26928] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 10/29/2021] [Accepted: 11/05/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND We assessed locoregional control with omission of intentional primary site radiation after transoral robotic surgery (TORS) and quantified nontargeted primary site dose. METHODS Following Institutional Review Board (IRB) approval, patients treated with primary TORS resection for squamous cell carcinomas of the oropharynx were reviewed. Patients with cT1-2 tumors, >2 mm margins, in whom the surgeon resected the primary without revising specimen-driven margins, qualified for omission of primary site radiation. RESULTS From 2014 to 2019, 112 patients met criteria. Fifty-nine (52%) patients did not receive radiation targeting the primary site; of whom, 22 received no radiation. In this group, there were no local failures; mean age was 58 years and median follow-up was 25 months. Thirty-seven patients received adjuvant radiation targeting the neck, mean bystander dose to the primary site was 28.8 Gy (range, 13.3-50.6 Gy). CONCLUSION In a 59 patient population, omission of radiation to the primary site after TORS resulted in no locoregional failures.
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Affiliation(s)
- Vishal R Dhere
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Chase E Escott
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - James P Bell
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - William A Stokes
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Mark W McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Brian J Boyce
- Department of Otolaryngology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Azeem S Kaka
- Department of Otolaryngology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Conor E Steuer
- Department of Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Nabil F Saba
- Department of Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Dong M Shin
- Department of Otolaryngology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Canhua Xiao
- Yale School of Nursing, New Haven, Connecticut, USA
| | - Mihir R Patel
- Department of Otolaryngology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Jonathan J Beitler
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA.,Department of Otolaryngology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA.,Department of Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
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13
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Zhou J, Yang X, Chang CW, Tian S, Wang T, Lin L, Wang Y, Janopaul-Naylor JR, Patel P, Demoor JD, Bohannon D, Stanforth A, Eaton B, McDonald MW, Liu T, Patel SA. Dosimetric Uncertainties in Dominant Intraprostatic Lesion Simultaneous Boost Using Intensity Modulated Proton Therapy. Adv Radiat Oncol 2021; 7:100826. [PMID: 34805623 PMCID: PMC8581277 DOI: 10.1016/j.adro.2021.100826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 08/27/2021] [Accepted: 09/20/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose While intensity modulated proton therapy can deliver simultaneous integrated boost (SIB) to the dominant intraprostatic lesion (DIL) with high precision, it is sensitive to anatomic changes. We investigated the dosimetric effects from these changes based on pretreatment cone-beam computed tomographic (CBCT) images and identified the most important factors using a multilayer perceptron neural network (MLPNN). Methods and Materials DILs were contoured based on coregistered multiparametric magnetic resonance images for 25 previously treated prostate cancer patients. SIB plans were created with (1) prostate clinical target volume − V70 Gy = 98%; (2) DIL − V98 Gy > 95%; and (3) all organs at risk (OARs)"?> within clinical constraints. SIB plans were applied to daily CBCT-based deformed planning computed tomography (CT)"?>. DIL − V98 Gy, bladder/rectum maximum dose (Dmax) and volume changes, femur shifts, and the distance from DIL to organs at riskOARs"?> in both planning computed tomogramsCT"?> and CBCT were calculated. Wilcoxon signed-ranks tests were used to compare the changes. MLPNNs were used to model the change in ΔDIL − V98 Gy > 10% and bladder/rectum Dmax > 80 Gy, and the relative importance factors for the model were provided. The performances of the models were evaluated with receiver operating characteristic curves. Results Comparing initial plan to the average from evaluation plans, respectively, DIL − V98 Gy was 89.3% ± 19.9% versus 86.2% ± 21.3% (P = .151); bladder Dmax 71.9 ± 0.6 Gy versus 74.5 ± 2.9 Gy (P < .001); and rectum Dmax 70.1 ± 2.4 Gy versus 74.9 ± 9.1Gy (P = .007). Bladder and rectal volumes were 99.6% ± 39.5% and 112.8% ± 27.2%, respectively, of their initial volume. The femur shift was 3.16 ± 2.52 mm. In the modeling of ΔDIL V98 Gy > 10%, DIL to rectum distance changes, DIL to bladder distance changes, and rectum volume changes ratio are the 3 most important factors. The areas under the receiver operating characteristic curves were 0.89, 1.00, and 0.99 for the modeling of ΔDIL − V98 Gy > 10%, and bladder and rectum Dmax > 80 Gy, respectively. Conclusions Dosimetric changes in DIL SIB with intensity modulated proton therapy can be modeled and classified based on anatomic changes on pretreatment images by an MLPNN.
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Affiliation(s)
- Jun Zhou
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Xiaofeng Yang
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Chih-Wei Chang
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Sibo Tian
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Tonghe Wang
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Liyong Lin
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Yinan Wang
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | | | - Pretesh Patel
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - John D Demoor
- Department of Medical Physics, Georgia Institute of Technology, Atlanta, Georgia
| | - Duncan Bohannon
- Department of Medical Physics, Georgia Institute of Technology, Atlanta, Georgia
| | - Alex Stanforth
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Bree Eaton
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Mark W McDonald
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Tian Liu
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
| | - Sagar Anil Patel
- Department of Radiation Oncology, Emory University, Atlanta, Georgia
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14
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Zhu M, Langen K, Nichols EM, Lin Y, Flampouri S, Godette KD, Dutta SW, McDonald MW, Patel SA. Intensity Modulated Proton Therapy Treatment Planning for Postmastectomy Patients with Metallic Port Tissue Expanders. Adv Radiat Oncol 2021; 7:100825. [PMID: 34805622 PMCID: PMC8590033 DOI: 10.1016/j.adro.2021.100825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 09/10/2021] [Accepted: 09/26/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose Proton beam therapy can significantly reduce cardiopulmonary radiation exposure compared with photon-based techniques in the postmastectomy setting for locally advanced breast cancer. For patients with metallic port tissue expanders, which are commonly placed in patients undergoing a staged breast reconstruction, dose uncertainties introduced by the high-density material pose challenges for proton therapy. In this report, we describe an intensity modulated proton therapy planning technique for port avoidance through a hybrid single-field optimization/multifield optimization approach. Methods and Materials In this planning technique, 3 beams are utilized. For each beam, no proton spot is placed within or distal to the metal port plus a 5 mm margin. Therefore, precise modeling of the metal port is not required, and various tissue expander manufacturers/models are eligible. The blocked area of 1 beam is dosimetrically covered by 1 or 2 of the remaining beams. Multifield optimization is used in the chest wall target region with blockage of any beam, while single-field optimization is used for remainder of chest wall superior/inferior to the port. Results Using this technique, clinical plans were created for 6 patients. Satisfactory plans were achieved in the 5 patients with port-to-posterior chest wall separations of 1.5 cm or greater, but not in the sixth patient with a 0.7 cm separation. Conclusions We described a planning technique and the results suggest that the metallic port-to-chest wall distance may be a key parameter for optimal plan design.
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Affiliation(s)
- Mingyao Zhu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Katja Langen
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Elizabeth M Nichols
- Department of Radiation Oncology, Maryland University School of Medicine, Baltimore, Maryland
| | - Yuting Lin
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Stella Flampouri
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Karen D Godette
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Sunil W Dutta
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Mark W McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - Sagar A Patel
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
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15
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Press RH, Shelton JW, Zhang C, Dang Q, Tian S, Shu T, Seldon CS, Hasan S, Jani AB, Zhou J, McDonald MW. Bone Marrow Suppression during Postoperative Radiation for Bladder Cancer and Comparative Benefit of Proton Therapy—Phase 2 Trial Secondary Analysis. Int J Part Ther 2021; 8:1-10. [PMID: 35127970 PMCID: PMC8768898 DOI: 10.14338/ijpt-21-00003.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 05/06/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose For patients with high-risk bladder cancer (pT3+ or N+), local regional failure remains a challenge after chemotherapy and cystectomy. An ongoing prospective phase 2 trial (NCT01954173) is examining the role of postoperative photon radiation therapy for high-risk patients using volumetric modulated arc therapy. Proton beam therapy (PBT) may be beneficial in this setting to reduce hematologic toxicity. We evaluated for dosimetric relationships with pelvic bone marrow (PBM) and changes in hematologic counts before and after pelvic radiation therapy and explored the potential of PBT treatment plans to achieve reductions in PBM dose. Materials and Methods All enrolled patients were retrospectively analyzed after pelvic radiation per protocol with 50.4 to 55.8 Gy in 28 to 31 fractions. Comparative PBT plans were generated using pencil-beam scanning and a 3-beam multifield optimization technique. Changes in hematologic nadirs were assessed using paired t test. Correlation of mean nadirs and relative PBM dose levels were assessed using the Pearson correlation coefficient (CC). Results Eighteen patients with a median age of 70 were analyzed. Mean cell count values after radiation therapy decreased compared with preradiation therapy values for white blood cells (WBCs), absolute neutrophil count (ANC), absolute lymphocyte count (all P < .001), and platelets (P = .03). Increased mean PBM dose was associated with lower nadirs in WBC (Pearson CC −0.593, P = .02), ANC (Pearson CC −0.597, P = .02), and hemoglobin (Pearson CC −0.506, P = .046), whereas the PBM V30 to V40 correlated with lower WBC (Pearson CC −0.512 to −0.618, P < .05), and V20 to V30 correlated with lower ANC (Pearson CC −0.569 to −0.598, P < .04). Comparative proton therapy plans decreased the mean PBM dose from 26.5 Gy to 16.1 Gy (P < .001) and had significant reductions in the volume of PBM receiving doses from 5 to 40 Gy (P < .001). Conclusion Increased PBM mean dose and V20 to V40 were associated with lower hematologic nadirs. PBT plans reduced PBM dose and may be a valuable strategy to reduce the risk of hematologic toxicity in these patients.
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Affiliation(s)
| | - Joseph W. Shelton
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Chao Zhang
- Biostatistics Core of Department Pediatrics, Emory University, Atlanta, GA, USA
| | - Quang Dang
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Timothy Shu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Crystal S. Seldon
- Department of Radiation Oncology, University of Miami Miller School of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, USA
| | | | - Ashesh B. Jani
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Jun Zhou
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Mark W. McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
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16
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Liu R, Lei Y, Wang T, Zhou J, Roper J, Lin L, McDonald MW, Bradley JD, Curran WJ, Liu T, Yang X. Synthetic dual-energy CT for MRI-only based proton therapy treatment planning using label-GAN. Phys Med Biol 2021; 66:065014. [PMID: 33596558 DOI: 10.1088/1361-6560/abe736] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
MRI-only treatment planning is highly desirable in the current proton radiation therapy workflow due to its appealing advantages such as bypassing MR-CT co-registration, avoiding x-ray CT exposure dose and reduced medical cost. However, MRI alone cannot provide stopping power ratio (SPR) information for dose calculations. Given that dual energy CT (DECT) can estimate SPR with higher accuracy than conventional single energy CT, we propose a deep learning-based method in this study to generate synthetic DECT (sDECT) from MRI to calculate SPR. Since the contrast difference between high-energy and low-energy CT (LECT) is important, and in order to accurately model this difference, we propose a novel label generative adversarial network-based model which can not only discriminate the realism of sDECT but also differentiate high-energy CT (HECT) and LECT from DECT. A cohort of 57 head-and-neck cancer patients with DECT and MRI pairs were used to validate the performance of the proposed framework. The results of sDECT and its derived SPR maps were compared with clinical DECT and the corresponding SPR, respectively. The mean absolute error for synthetic LECT and HECT were 79.98 ± 18.11 HU and 80.15 ± 16.27 HU, respectively. The corresponding SPR maps generated from sDECT showed a normalized mean absolute error as 5.22% ± 1.23%. By comparing with the traditional Cycle GANs, our proposed method significantly improves the accuracy of sDECT. The results indicate that on our dataset, the sDECT image form MRI is close to planning DECT, and thus shows promising potential for generating SPR maps for proton therapy.
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Affiliation(s)
- Ruirui Liu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States of America
| | - Yang Lei
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States of America
| | - Tonghe Wang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States of America
| | - Jun Zhou
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States of America
| | - Justin Roper
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States of America
| | - Liyong Lin
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States of America
| | - Mark W McDonald
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States of America
| | - Jeffrey D Bradley
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States of America
| | - Walter J Curran
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States of America
| | - Tian Liu
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States of America
| | - Xiaofeng Yang
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA 30322, United States of America
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17
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Marks JA, Switchenko JM, Steuer CE, Ryan M, Patel MR, McDonald MW, Higgins K, Beitler JJ, Shin DM, Gillespie TW, Saba NF. Socioeconomic Factors Influence the Impact of Tumor HPV Status on Outcome of Patients With Oropharyngeal Squamous Cell Carcinoma. JCO Oncol Pract 2021; 17:e313-e322. [PMID: 33434083 DOI: 10.1200/op.20.00671] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Human papilloma virus (HPV) association remains one of the most important predictors of clinical outcome in oropharyngeal squamous cell carcinoma (OPSCC). We aimed to determine whether the relationship between HPV status and overall survival was influenced by socioeconomic factors. MATERIALS AND METHODS Using the National Cancer Database, we examined the relationship between socioeconomic status and overall survival, controlling for demographics and socioeconomic variables (age at diagnosis, race, sex, clinical stage, facility type, facility location, insurance status, median-income quartiles, percent of no high-school education quartiles, rural-urban dwelling, Charlson-Deyo score, primary site, and treatment type). RESULTS HPV-positive patients with private insurance have improved overall survival compared with HPV-positive patients who are uninsured (hazard ratio [HR], 0.51, 95% CI, 0.41 to 0.63, P < .001). HPV-negative patients with private insurance have improved overall survival compared with HPV-negative patients who were uninsured (HR, 0.62, 95% CI, 0.53 to 0.73, P < .001). HPV-positive patients living in the south had improved overall survival compared with HPV-positive patients living in the west (HR, 0.83, 95% CI, 0.72 to 0.96, P = .013). As assessed through interaction, relationships between survival and insurance (P = .004), rural-urban status (P = .009), and facility location (P = .021) statistically differed between HPV-positive and HPV-negative patients. CONCLUSION HPV status impact on overall survival for patients with OPSCC is influenced by socioeconomic factors including insurance status and treatment facility. A deeper understanding of these interactions is needed to improve equity of care for patients with OPSCC.
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Affiliation(s)
- Jennifer A Marks
- Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jeffrey M Switchenko
- Department of Biostatistics & Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Conor E Steuer
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA
| | - Martha Ryan
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA
| | - Mihir R Patel
- Department of Otolaryngology, Emory University School of Medicine, Atlanta, GA
| | - Mark W McDonald
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA
| | - Kristin Higgins
- Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA
| | - Johnathan J Beitler
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA.,Department of Otolaryngology, Emory University School of Medicine, Atlanta, GA.,Department of Radiation Oncology, Emory University School of Medicine, Atlanta, GA
| | - Dong M Shin
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA
| | | | - Nabil F Saba
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA
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18
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Qian DC, Magliocca KR, Aiken AH, Baugnon KL, Brandon DC, Stokes WA, McDonald MW, Patel MR, Baddour HM, Kaka AS, Steuer CE, Saba NF, Shin DM, Beitler JJ. Outcomes and Predictive Value of Post-adjuvant Therapy PET/CT for Locally Advanced Oral Squamous Cell Carcinoma. Laryngoscope 2020; 130:E850-E857. [PMID: 32057110 DOI: 10.1002/lary.28509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 12/23/2019] [Accepted: 01/07/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS For locally advanced oral squamous cell carcinoma (OSCC) treated by surgery and adjuvant therapy, consensus has yet to be reached on whether the optimal time to initiate surveillance positron emission tomography/computed tomography (PET/CT) scan is before or after adjuvant therapy. In this study, we characterize the utility of PET/CT scans obtained 3 months after adjuvant therapy. STUDY DESIGN PET/CT scans were obtained for 220 patients with stage III, IVA, or IVB OSCC who underwent resection followed by adjuvant radiotherapy or chemoradiotherapy. METHODS Using the Neck Imaging Reporting and Data System, PET/CT scans were dichotomized as suspicious (primary or neck category ≥3, or distant lesion present) versus nonsuspicious. We then computed differences in locoregional progression, distant progression, and overall survival; positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity; and success rate of salvage. RESULTS Sixty-seven patients (30%) had suspicious PET/CT scans, which were significantly associated with local failure (hazard ratio [HR] 14.0, 95% confidence interval [CI] 7.3-26.6), distant failure (HR 18.4, 95% CI 9.6-35.3), and poorer overall survival (HR 9.5, 95% CI 5.0-17.9). Overall PPV, locoregional PPV, NPV, sensitivity, and specificity were 85%, 79%, 73%, 58%, and 92%, respectively. Among those with biopsy-confirmed progression, 37 patients (65%) underwent salvage therapy; four (11%) were without evidence of disease at last follow-up. CONCLUSIONS For locally advanced OSCC, PET/CT scan 3 months after adjuvant therapy is strongly predictive of disease recurrence and survival, demonstrating improved performance over postoperative imaging in previous studies. Following a suspicious post-adjuvant therapy PET/CT scan, cure of locoregional recurrence is possible but unlikely. LEVEL OF EVIDENCE 4 Laryngoscope, 2020.
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Affiliation(s)
- David C Qian
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Kelly R Magliocca
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ashley H Aiken
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kristen L Baugnon
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David C Brandon
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - William A Stokes
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Mark W McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Mihir R Patel
- Department of Otolaryngology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Harry M Baddour
- Department of Otolaryngology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Azeem S Kaka
- Department of Otolaryngology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Conor E Steuer
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Nabil F Saba
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Dong M Shin
- Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | - Jonathan J Beitler
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA.,Department of Otolaryngology, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Hematology and Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
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19
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Tian S, Jiang R, Madden NA, Ferris MJ, Buchwald ZS, Xu KM, Cardona K, Maithel SK, McDonald MW, Lin JY, Curran WJ, El-Rayes BF, Behera M, Patel PR. Survival outcomes in patients with gastric and gastroesophageal junction adenocarcinomas treated with perioperative chemotherapy with or without preoperative radiotherapy. Cancer 2019; 126:37-45. [PMID: 31532544 DOI: 10.1002/cncr.32516] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/08/2019] [Accepted: 08/10/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Perioperative chemotherapy (POC) is one standard approach for the treatment of resectable cancers of the stomach and gastroesophageal junction (GEJ), whereas there has been growing interest in preoperative therapies. The objective of the current study was to compare survival between patients treated with preoperative chemoradiotherapy and adjuvant chemotherapy (PCRT) with those receiving POC using a large database. METHODS The National Cancer Data Base was queried for patients diagnosed between 2004 and 2013 with American Joint Committee on Cancer clinical group stage IB to stage IIIC (excluding T2N0 disease) adenocarcinoma of the stomach or GEJ. Patients treated with definitive surgery and POC with or without preoperative radiotherapy of 41 to 54 Gy were included. Overall survival (OS) was defined from the date of definitive surgery and estimated using the Kaplan-Meier method. A total of 14 patient and treatment variables were used for propensity score matching (PSM). RESULTS A total of 1048 patients were analyzed: 53.2% received POC and 46.8% received PCRT. The primary tumor site was the GEJ in 69.1% of patients and stomach in 30.9% of patients. The median age of the patients was 60 years, and the median follow-up was 25.8 months. The use of PCRT was associated with a greater pathologic complete response rate of 13.1% versus 8.2% (P = .01). POC was associated with a decreased risk of death in unmatched groups (hazard ratio [HR], 0.83; P = .043). Using PSM cohorts, POC decreased the risk of death with a median OS of 45.1 months versus 31.4 months (HR, 0.70; P = .016). The 2-year OS rate was 72.9% versus 62.5% and the 5-year OS rate was 40.7% versus 33.1% for POC versus PCRT, respectively. Survival favored POC in PSM gastric (HR, 0.41; P = .07) and GEJ (HR, 0.77; P = .08) patient subgroups. CONCLUSIONS The addition of preoperative radiotherapy to POC appears to be associated with an increased risk of death in patients with resectable gastric and GEJ cancers.
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Affiliation(s)
- Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Renjian Jiang
- Winship Research Informatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Nicholas A Madden
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Matthew J Ferris
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Zachary S Buchwald
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Karen M Xu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kenneth Cardona
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mark W McDonald
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jolinta Y Lin
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Bassel F El-Rayes
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Madhusmita Behera
- Winship Research Informatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Pretesh R Patel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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20
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Abugideiri M, Schreibmann E, Switchenko J, McDonald MW, Beitler JJ, Curran WJ, Bruner D, Patel P, Tigeneh W, Mijena M, Tian S, Dhabaan A, Esiashvili N, Liu T, Ali AN. Prospective International Pilot Study Evaluating the Efficacy of a Self-Guided Contouring Teaching Module With Integrated Feedback for Transitioning From 2D to 3D Treatment Planning. J Glob Oncol 2019; 5:1-16. [PMID: 31082303 PMCID: PMC6550062 DOI: 10.1200/jgo.18.00224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSE Transitioning from two-dimensional to three-dimensional treatment planning requires developing contouring skills. Contouring atlases are excellent resources, but they do not provide users active feedback. Developing countries may not have many radiation oncologists experienced in three-dimensional planning to provide training. We sought to develop a standardized self-guided educational module with integrated feedback to teach contouring skills. METHODS AND MATERIALS All 18 oncology residents at Black Lion Hospital/Addis Ababa University in Ethiopia were trained to contour the level II lymph node station. Residents took a baseline pretest quiz, survey, and contouring evaluation. Residents then watched an instructional contouring lecture and performed three additional cases with integrated feedback by comparing their contours to gold-standard contours. Residents then took a post-training quiz, survey, and contouring evaluation. Paired t tests and analysis of variance were used for analysis. RESULTS Before training, the average number of total cases ever contoured was 2.4 and the average number of head and neck cases contoured was 0.5. Comfort with contouring improved from being “not at all comfortable” to “quite comfortable” after the 3-hour training (P < .001). The standard deviation between the resident contours and gold standard improved from 72.6 cm3 (pretest) to 7.4 cm3 (post-test). The average percentage overlap with the gold-standard contours and Dice similarity coefficient improved with each case performed, from 27.7% and 0.26 (pretest) to 80.1% and 0.77 (post-test), respectively (P < .001). After training, 16 of 18 (88.9%) residents produced a Dice similarity coefficient greater than 0.7, the threshold generally accepted for excellent agreement. CONCLUSION This self-guided teaching module was an effective tool for developing level II lymph node contouring skills by providing active feedback and resulted in improved user confidence and accuracy compared with a gold standard. This module can be expanded to other disease sites and countries to further facilitate transitioning to three-dimensional treatment planning in developing countries.
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Affiliation(s)
| | | | | | | | | | | | - Deborah Bruner
- Winship Cancer Institute of Emory University, Atlanta, GA
| | - Pretesh Patel
- Winship Cancer Institute of Emory University, Atlanta, GA
| | | | - Miressa Mijena
- Black Lion Hospital/Addis Ababa University, Addis Ababa, Ethiopia
| | - Sibo Tian
- Winship Cancer Institute of Emory University, Atlanta, GA
| | - Anees Dhabaan
- Winship Cancer Institute of Emory University, Atlanta, GA
| | | | - Tian Liu
- Winship Cancer Institute of Emory University, Atlanta, GA
| | - Arif N Ali
- Winship Cancer Institute of Emory University, Atlanta, GA
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21
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Tian S, Switchenko JM, Jhaveri J, Cassidy RJ, Ferris MJ, Press RH, Pfister NT, Patel MR, Saba NF, McDonald MW, Higgins KA, Yu DS, Curran WJ, Gillespie TW, Beitler JJ. Survival outcomes by high-risk human papillomavirus status in nonoropharyngeal head and neck squamous cell carcinomas: A propensity-scored analysis of the National Cancer Data Base. Cancer 2019; 125:2782-2793. [PMID: 31012957 DOI: 10.1002/cncr.32115] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/22/2019] [Accepted: 03/05/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND The prognostic relevance of human papillomavirus (HPV) status in patients with nonoropharyngeal (OPX) squamous cell cancer (SCC) of the head and neck is controversial. In the current study, the authors evaluated the impact of high-risk HPV status on overall survival (OS) in patients with non-OPX SCC using a large database approach. METHODS The National Cancer Data Base was queried to identify patients diagnosed from 2004 through 2014 with SCC of the OPX, hypopharynx (HPX), larynx, and oral cavity (OC) with known HPV status. Survival was estimated using Kaplan-Meier methods; distributions were compared using log-rank tests. Propensity score-matching and inverse probability of treatment weighing (IPTW) methods were used; cohorts were matched based on age, sex, Charlson-Deyo score, clinical American Joint Committee on Cancer (AJCC) group stage, treatments received, and anatomic subsite. Propensity analyses were stratified by group stage of disease. RESULTS A total of 24,740 patients diagnosed from 2010 through 2013 were analyzed: 1085 patients with HPX, 4804 with laryngeal, 4,018 with OC, and 14,833 with OPX SCC. The percentages of HPV-positive cases by disease site were 17.7% for HPX, 11% for larynx, 10.6% for OC, and 62.9% for OPX. HPV status was found to be prognostic in multiple unadjusted and propensity-adjusted non-OPX populations. HPV positivity was associated with superior OS in patients with HPX SCC with a hazard ratio (HR) of 0.61 (P < .001 by IPTW), in patients with AJCC stage III to IVB laryngeal SCC (HR, 0.79; P = .019 by IPTW), and in patients with AJCC stage III to IVB OC SCC (HR, 0.78; P = .03 by IPTW). CONCLUSIONS Positive high-risk HPV status appears to be associated with longer OS in multiple populations of patients with non-OPX head and neck disease (HPX, locally advanced larynx, and OC). If prospectively validated, these findings have implications for risk stratification.
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Affiliation(s)
- Sibo Tian
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jeffrey M Switchenko
- Department of Biostatistics and Bioinformatics, Rollins School of Public Heath, Emory University, Atlanta, Georgia
| | - Jaymin Jhaveri
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Richard J Cassidy
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Matthew J Ferris
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Robert H Press
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Neil T Pfister
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mihir R Patel
- Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia
| | - Nabil F Saba
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Mark W McDonald
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Kristin A Higgins
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David S Yu
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Walter J Curran
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Theresa W Gillespie
- Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Jonathan J Beitler
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia.,Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia.,Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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22
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Cassidy RJ, Switchenko JM, El-Deiry MW, Belcher RH, Zhong J, Steuer CE, Saba NF, McDonald MW, Yu DS, Gillespie TW, Beitler JJ. Disparities in Postoperative Therapy for Salivary Gland Adenoid Cystic Carcinomas. Laryngoscope 2019; 129:377-386. [PMID: 30194768 PMCID: PMC6344280 DOI: 10.1002/lary.27302] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The patterns of care for salivary gland adenoid cystic carcinomas (ACC) are unknown. We sought to assess predictors of receiving postoperative radiation and/or chemotherapy for patients with nonmetastatic, definitively resected ACC, as well as report unexpected nodal disease. METHODS The National Cancer Data Base was queried for definitively resected nonmetastatic ACC from 2004 to 2014. Logistic regression, Kaplan-Meier, and Cox proportional-hazard models were utilized. Propensity-score matched analysis was employed to reduce confounding variables. RESULTS A total of 3,136 patients met entry criteria: 2,252 (71.8%) received postoperative radiation, with 223 (7.4%) also receiving concurrent chemotherapy. Median follow-up was 4.87 years. In clinically lymph node negative (cN0) patients, 7.4% had pathologically positive lymph nodes (pN) + after elective neck dissection. Patients who lived closer to their treatment facility and had positive margins were more likely to receive postoperative radiation. Black patients and uninsured patients were less likely to receive radiation. Older age, male sex, advancing stage, and positive surgical margins were associated with worse overall survival (OS). With limited follow-up, receipt of radiation or chemotherapy was not associated with OS. CONCLUSION Postoperative radiation was frequently given for resected ACC, with a minority receiving chemotherapy. Black patients and uninsured patients were less likely to receive radiation. Postoperative radiation and/or chemotherapy had no association with OS but were given in greater frequency in more advanced disease, and our series is limited by short follow-up. The disparity findings for this rare disease need to be addressed in future studies. LEVEL OF EVIDENCE 2c Laryngoscope, 129:377-386, 2019.
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Affiliation(s)
- Richard J. Cassidy
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Jeffrey M. Switchenko
- Department of Biostatistics and Bioinformatics, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Mark W. El-Deiry
- Department of Otolaryngology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Ryan H. Belcher
- Department of Otolaryngology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Jim Zhong
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Conor E. Steuer
- Department of Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Nabil F. Saba
- Department of Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Mark W. McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - David S. Yu
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Theresa W. Gillespie
- Department of Surgery, Winship Cancer Institute of Emory University, Atlanta, GA, USA
| | - Jonathan J. Beitler
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
- Department of Otolaryngology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
- Department of Medical Oncology, Winship Cancer Institute of Emory University, Atlanta, GA, USA
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23
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Beitler JJ, Switchenko JM, Dignam JJ, McDonald MW, Saba NF, Shin DM, Magliocca KR, Cassidy RJ, El-Deiry MW, Patel MR, Steuer CE, Xiao C, Hudgins PA, Aiken AH, Curran WJ, Le QT. Smoking, age, nodal disease, T stage, p16 status, and risk of distant metastases in patients with squamous cell cancer of the oropharynx. Cancer 2018; 125:704-711. [PMID: 30548235 DOI: 10.1002/cncr.31820] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 09/16/2018] [Accepted: 09/24/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND With an expectation of excellent locoregional control, ongoing efforts to de-intensify therapy for patients with human papillomavirus-associated squamous cell oropharyngeal cancer necessitate a better understanding of the metastatic risk for patients with this disease. The objective of this study was to determine what factors affect the risk of metastases in patients with squamous cell cancers of the oropharynx. METHODS Under a shared use agreement, 547 patients from Radiation Therapy Oncology Group 0129 and 0522 with nonmetastatic oropharyngeal squamous cell cancers who had a known p16 status and smoking status were analyzed to assess the association of clinical features with the development of distant metastases. The analyzed factors included the p16 status, sex, T stage, N stage, age, and smoking history. RESULTS A multivariate analysis of 547 patients with a median follow-up of 4.8 years revealed that an age ≥ 50 years (hazard ratio [HR], 3.28; P = .003), smoking for more than 0 pack-years (HR, 3.09; P < .001), N3 disease (HR, 2.64; P < .001), T4 disease (HR, 1.63; P = .030), and a negative p16 status (HR, 1.60; P = .044) were all factors associated with an increased risk of distant disease. CONCLUSIONS Age, smoking, N3 disease, T4 disease, and a negative p16 status were associated with the development of distant metastases in patients with squamous cell cancers of the oropharynx treated definitively with concurrent chemoradiation.
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Affiliation(s)
- Jonathan J Beitler
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Mark W McDonald
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Nabil F Saba
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Dong M Shin
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Kelly R Magliocca
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Richard J Cassidy
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Mark W El-Deiry
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Mihir R Patel
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Conor E Steuer
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Canhua Xiao
- School of Nursing, Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Patricia A Hudgins
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Ashley H Aiken
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia
| | - Walter J Curran
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia.,NRG Oncology
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24
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Jhaveri J, Cheng E, Tian S, Buchwald Z, Chowdhary M, Liu Y, Gillespie TW, Olson JJ, Diaz AZ, Voloschin A, Eaton BR, Crocker IR, McDonald MW, Curran WJ, Patel KR. Proton vs. Photon Radiation Therapy for Primary Gliomas: An Analysis of the National Cancer Data Base. Front Oncol 2018; 8:440. [PMID: 30547008 PMCID: PMC6279888 DOI: 10.3389/fonc.2018.00440] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 09/20/2018] [Indexed: 11/13/2022] Open
Abstract
Background: To investigate the impact of proton radiotherapy (PBT) on overall survival (OS) and evaluate PBT usage trends for patients with gliomas in the National Cancer Data Base (NCDB). Methods: Patients with a diagnosis of World Health Organization (WHO) Grade I-IV glioma treated with definitive radiation therapy (RT) between the years of 2004–13 were identified. Patients were stratified based on WHO Grade and photon radiotherapy (XRT) vs. PBT. Univariate (UVA) and multivariable analysis (MVA) with OS were performed by Cox proportional hazards model and log-rank tests. Propensity score (PS) weighting was utilized to account for differences in patient characteristics and to minimize selection bias. Results: There were a total of 49,405 patients treated with XRT and 170 patients treated with PBT. Median follow-up time was 62.1 months. On MVA, the following factors were associated with receipt of PBT (all p < 0.05): WHO Grade I-II gliomas, treatment at an academic/research program, west geographic facility location, and surgical resection. After PS weighting, all patients treated with PBT were found to have superior median and 5 year survival than patients treated with XRT: 45.9 vs. 29.7 months (p = 0.009) and 46.1 vs. 35.5% (p = 0.0160), respectively. Conclusions: PBT is associated with improved OS compared to XRT for patients with gliomas. This finding warrants verification in the randomized trial setting in order to account for potential patient imbalances not adequately captured by the NCDB, such as tumor molecular characteristics and patient performance status. Importance of the Study: This is the first study that compares the outcomes of patients treated with photon based radiotherapy vs. proton based radiotherapy for patients with gliomas. In this retrospective analysis, the results demonstrate that proton therapy is associated with improved outcomes which support ongoing prospective, randomized clinical trials comparing the two modalities in patients with gliomas.
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Affiliation(s)
- Jaymin Jhaveri
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - En Cheng
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Sibo Tian
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Zachary Buchwald
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Mudit Chowdhary
- Department of Radiation Oncology, Rush University, Chicago, IL, United States
| | - Yuan Liu
- Biostatistics and Bioinformatics Shared Resource, Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | | | - Jeffrey J Olson
- Department of Neurosurgery and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Aidnag Z Diaz
- Department of Radiation Oncology, Rush University, Chicago, IL, United States
| | - Alfredo Voloschin
- Department of Hematology and Medical Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Bree R Eaton
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Ian R Crocker
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Mark W McDonald
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Walter J Curran
- Department of Radiation Oncology and Winship Cancer Institute, Emory University, Atlanta, GA, United States
| | - Kirtesh R Patel
- Department of Therapeutic Radiology, Yale University, New Haven, CT, United States
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25
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Zhong J, Switchenko J, Behera M, Kooby D, Maithel SK, McDonald MW, Lin JY, Cassidy RJ, El-Rayes B, Landry J, Patel PR. Chemotherapy with or Without Definitive Radiation Therapy in Inoperable Pancreatic Cancer. Ann Surg Oncol 2018; 25:1026-1033. [PMID: 29327180 DOI: 10.1245/s10434-017-6322-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND The LAP07 randomized trial calls into question the role of radiation therapy (RT) in the modern treatment of locally advanced pancreatic cancer (LAPC). However, advances in chemotherapy and RT limit application of the LAP07 results to current clinical practice. Here we utilize the National Cancer Database (NCDB) to evaluate the effects of RT in patients receiving chemotherapy for LAPC. METHODS Using the NCDB, patients with American Joint Committee on Cancer (AJCC) clinical stage T2-4, N0-1, M0 adenocarcinoma of the pancreas from 2004 to 2014 were analyzed. Patients were stratified into chemotherapy only (CT) and chemoradiation (CRT) cohorts. Patients undergoing definitive RT, defined as at least 20 fractions or ≥ 5 Gy per fraction [i.e., stereotactic body radiation therapy (SBRT)] were included in the CRT cohort. Propensity-score matching (PSM) and landmark analysis were used to address selection bias and lead-time bias, respectively. RESULTS 13,004 patients met inclusion criteria, of whom 7034 (54%) received CT and 5970 (46%) received CRT. After PSM, 5215 patients remained in each cohort. The CRT cohort demonstrated better overall survival (OS) compared with CT alone, with median and 1-year OS of 12 versus 10 months, and 50% and 41%, respectively (p < 0.001). On multivariable analysis, CRT was associated with superior OS with hazard ratio of 0.79 (95% confidence interval 0.76-0.83) compared with CT alone. CONCLUSIONS In our series, addition of definitive radiotherapy to CT was associated with better OS when compared with CT alone in LAPC. Definitive radiotherapy should remain a treatment option for LAPC, but optimal selection criteria remain unclear.
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Affiliation(s)
- Jim Zhong
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA. .,Winship Cancer Institute, Emory University, Atlanta, GA, USA.
| | - Jeffrey Switchenko
- Winship Cancer Institute, Emory University, Atlanta, GA, USA.,Department of Biostatistics & Bioinformatics, Emory University, Atlanta, GA, USA
| | - Madhusmita Behera
- Winship Cancer Institute, Emory University, Atlanta, GA, USA.,Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA
| | - David Kooby
- Winship Cancer Institute, Emory University, Atlanta, GA, USA.,Department of Surgery, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Winship Cancer Institute, Emory University, Atlanta, GA, USA.,Department of Surgery, Emory University, Atlanta, GA, USA
| | - Mark W McDonald
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA.,Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jolinta Y Lin
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA.,Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Richard J Cassidy
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA.,Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Bassel El-Rayes
- Winship Cancer Institute, Emory University, Atlanta, GA, USA.,Department of Hematology and Medical Oncology, Emory University, Atlanta, GA, USA
| | - Jerome Landry
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA.,Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Pretesh R Patel
- Department of Radiation Oncology, Emory University, Atlanta, GA, USA.,Winship Cancer Institute, Emory University, Atlanta, GA, USA
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26
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Ferris MJ, Zhong J, Switchenko JM, Higgins KA, Cassidy RJ, McDonald MW, Eaton BR, Patel KR, Steuer CE, Baddour HM, Miller AH, Bruner DW, Xiao C, Beitler JJ. Brainstem dose is associated with patient-reported acute fatigue in head and neck cancer radiation therapy. Radiother Oncol 2018; 126:100-106. [PMID: 28826628 PMCID: PMC5841457 DOI: 10.1016/j.radonc.2017.08.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 07/17/2017] [Accepted: 08/05/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE Radiation (RT) dose to the central nervous system (CNS) has been implicated as a contributor to treatment-related fatigue in head and neck cancer (HNC) patients undergoing radiation therapy (RT). This study evaluates the association of RT dose to CNS structures with patient-reported (PRO) fatigue scores in a population of HNC patients. MATERIALS AND METHODS At pre-RT (baseline), 6th week of RT, and 1-month post-RT time points, Multidimensional Fatigue Inventory (MFI-20) scores were prospectively obtained from 124 patients undergoing definitive treatment for HNC. Medulla, pons, midbrain, total brainstem, cerebellum, posterior fossa, and pituitary dosimetry were evaluated using summary statistics and dose-volume histograms, and associations with MFI-20 scores were analyzed. RESULTS Maximum dose (Dmax) to the brainstem and medulla was significantly associated with MFI-20 scores at 6th week of RT and 1-month post-RT time points, after controlling for baseline scores (p<0.05). Each 1Gy increase in medulla Dmax resulted in an increase in total MFI-20 score over baseline of 0.30 (p=0.026), and 0.25 (p=0.037), at the 6th week of RT and 1-month post-RT, respectively. Each 1Gy increase in brainstem Dmax resulted in an increase in total MFI-20 score over baseline of 0.30 (p=0.027), and 0.25 (p=0.037) at the 6th week of RT, 1-month post-RT, respectively. Statistically significant associations were not found between dosimetry for the other CNS structures and MFI-20 scores. CONCLUSIONS In this analysis of PRO fatigue scores from a population of patients undergoing definitive RT for HNC, maximum dose to the brainstem and medulla was associated with a significantly increased risk of acute patient fatigue.
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Affiliation(s)
- Matthew J Ferris
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA.
| | - Jim Zhong
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| | - Jeffrey M Switchenko
- Winship Cancer Institute of Emory University, Atlanta, USA; Department of Biostatistics & Bioinformatics, Emory University, Atlanta, USA
| | - Kristin A Higgins
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| | - Richard J Cassidy
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| | - Mark W McDonald
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| | - Bree R Eaton
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| | - Kirtesh R Patel
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
| | - Conor E Steuer
- Winship Cancer Institute of Emory University, Atlanta, USA; Department of Hematology and Medical Oncology, Emory University, Atlanta, USA
| | - H Michael Baddour
- Winship Cancer Institute of Emory University, Atlanta, USA; Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, USA
| | - Andrew H Miller
- Winship Cancer Institute of Emory University, Atlanta, USA; Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, USA
| | - Deborah W Bruner
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, USA
| | - Canhua Xiao
- Winship Cancer Institute of Emory University, Atlanta, USA; Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, USA
| | - Jonathan J Beitler
- Department of Radiation Oncology, Emory University, Atlanta, USA; Winship Cancer Institute of Emory University, Atlanta, USA
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27
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Bell JP, Patel P, Higgins K, McDonald MW, Roper J. Fine-tuning the normal tissue objective in eclipse for lung stereotactic body radiation therapy. Med Dosim 2017; 43:344-350. [PMID: 29277249 DOI: 10.1016/j.meddos.2017.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 11/13/2017] [Accepted: 11/13/2017] [Indexed: 12/31/2022]
Abstract
The purpose of this study was to characterize the effects of the normal tissue objective (NTO) on lung stereotactic body radiation therapy (SBRT) dose distributions. The NTO is a spatially varying constraint used in Eclipse to limit dose to normal tissues by steepening the dose gradient. However, the multitude of potential NTO setting combinations challenges optimal NTO tuning. In the present study, a broad range of NTO settings are investigated for lung SBRT treatment planning with volumetric modulated arc therapy(VMAT). Ten prior lung SBRT cases were replanned using NTO priorities of 1, 50, 100, 200, 500, and 999 in combination with fall-off values of 0.01, 0.05, 0.10, 0.15, 0.20, 0.30, 0.50, 1.00, and 5.00 mm-1 and the automatic NTO. NTO distances to planning target volume (PTV), start dose, and end dose were 1 mm, 100%, and 10%, respectively, for all 600 plans. Prescription dose covered 95% of the PTV. The following metrics were recorded: conformity index (CI), ratio of the 50% prescription isodose volume to PTV (R50%), maximum dose 2 cm away from PTV (D2cm), lung volume of ≥20 Gy (V20Gy), maximum PTV dose (PTVmax), and monitor units (MUs). Differences between prior plans and NTO plans were evaluated using the Wilcoxon signed-rank test. Different combinations of NTO settings resulted in wide-ranging plan quality metrics: CI (1.00 to 1.54), R50% (3.95 to 7.57), D2cm (33.4% to 67.9%), V20Gy (1.66% to 2.75%), MU (1.81 cGy-1 to 4.69 cGy-1), and PTVmax (118% to 175%). Although no settings were optimal for all metrics, a fall-off of 0.15 mm-1 and a priority of 500 best satisfied institutional criteria. Compared with prior plans, NTO plans resulted in significantly lower R50% (4.00 vs 4.35, p = 0.002), lower V20Gy (1.22% vs 1.32%, p = 0.006), and higher PTVmax (138% vs 122%, p = 0.002). All of the prior and well-tuned NTO plans met Radiation Therapy Oncology Group (RTOG) 0813 guidelines. Lung SBRT dose distributions were characterized across a range of NTO settings. NTO plans with well-tuned settings compared favorably with prior plans.
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Affiliation(s)
- James P Bell
- Department of Radiation Oncology, Simmons Comprehensive Cancer Center at the University of Texas Southwestern Medical Center, Dallas, TX
| | - Pretesh Patel
- Winship Cancer Institute of Emory University, 1356 Clifton Road NE, Building C, Atlanta, Georgia 30322
| | - Kristin Higgins
- Winship Cancer Institute of Emory University, 1356 Clifton Road NE, Building C, Atlanta, Georgia 30322
| | - Mark W McDonald
- Hospital Corporation of America, Sarah Cannon Cancer Center, Department of Radiation Oncology, 2410 Patterson Street, Basement Level, Nashville, TN 37203
| | - Justin Roper
- Hospital Corporation of America, Sarah Cannon Cancer Center, Department of Radiation Oncology, 2410 Patterson Street, Basement Level, Nashville, TN 37203.
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28
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Cassidy RJ, Switchenko JM, Cheng E, Jiang R, Jhaveri J, Patel K, Tanenbaum DG, Russell MC, Steuer CE, Gillespie TW, McDonald MW, Landry JC. Health care disparities among octogenarians and nonagenarians with stage II and III rectal cancer. Cancer 2017; 123:4325-4336. [PMID: 28759121 PMCID: PMC5673500 DOI: 10.1002/cncr.30896] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/21/2017] [Accepted: 06/26/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Octogenarians and nonagenarians with stage II/III rectal adenocarcinomas are underrepresented in the randomized trials that have established the standard-of-care therapy of preoperative chemoradiation followed by definitive resection (ie, chemoradiation and then surgery [CRT+S]). The purpose of this study was to evaluate the impact of therapies on overall survival (OS) for patients with stage II/III rectal cancers and determine predictors of therapy within the National Cancer Data Base (NCDB). METHODS In the NCDB, patients who were 80 years old or older and had clinical stage II/III rectal adenocarcinoma from 2004 to 2013 were queried. Kaplan-Meier analysis, log-rank testing, logistic regression, Cox proportional hazards regression, interaction effect testing, and propensity score-matched analysis were conducted. RESULTS The criteria were met by 2723 patients: 14.9% received no treatment, 29.7% had surgery alone, 5.0% underwent short-course radiation and then surgery (RT+S), 45.3% underwent CRT+S, and 5.1% underwent surgery and then chemoradiation (S+CRT). African American race and residence in a less educated county were associated with not receiving treatment. Male sex, older age, worsening comorbidities, and receiving no treatment or undergoing surgery alone were associated with worse OS. There was no statistical difference in OS between RT+S, S+CRT, and CRT+S. Interaction testing found that CRT+S improved OS independently of age, comorbidity status, sex, race, and tumor stage. In the propensity score-matched analysis, CRT+S was associated with improved OS in comparison with surgery alone. CONCLUSIONS A significant portion of octogenarians and nonagenarians with stage II/III rectal adenocarcinomas do not receive treatment. African American race and living in a less educated community are associated with not receiving therapy. This series suggests that CRT+S is a reasonable strategy for elderly patients who can tolerate therapy. Cancer 2017;123:4325-36. © 2017 American Cancer Society.
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Affiliation(s)
- Richard J. Cassidy
- Department of Radiation Oncology, Emory University, Atlanta, GA
- Winship Cancer Institute, Emory University, Atlanta, GA
| | | | - En Cheng
- Department of Biostatistics and Bioinformatics, Emory University, Atlanta, GA
| | - Renjian Jiang
- Department of Epidemiology, Emory University, Atlanta, GA
| | - Jaymin Jhaveri
- Department of Radiation Oncology, Emory University, Atlanta, GA
- Winship Cancer Institute, Emory University, Atlanta, GA
| | - Kirtesh Patel
- Department of Radiation Oncology, Emory University, Atlanta, GA
- Winship Cancer Institute, Emory University, Atlanta, GA
| | - Daniel G. Tanenbaum
- Department of Radiation Oncology, Emory University, Atlanta, GA
- Winship Cancer Institute, Emory University, Atlanta, GA
| | - Maria C. Russell
- Department of Surgery, Emory University, Atlanta, GA
- Winship Cancer Institute, Emory University, Atlanta, GA
| | - Conor E. Steuer
- Department of Medical Oncology, Emory University, Atlanta, GA
- Winship Cancer Institute, Emory University, Atlanta, GA
| | - Theresa W. Gillespie
- Department of Surgery, Emory University, Atlanta, GA
- Department of Medical Oncology, Emory University, Atlanta, GA
| | - Mark W. McDonald
- Department of Radiation Oncology, Emory University, Atlanta, GA
- Winship Cancer Institute, Emory University, Atlanta, GA
| | - Jerome C. Landry
- Department of Radiation Oncology, Emory University, Atlanta, GA
- Winship Cancer Institute, Emory University, Atlanta, GA
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29
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Higgins KA, O'Connell K, Liu Y, Gillespie TW, McDonald MW, Pillai RN, Patel KR, Patel PR, Robinson CG, Simone CB, Owonikoko TK, Belani CP, Khuri FR, Curran WJ, Ramalingam SS, Behera M. National Cancer Database Analysis of Proton Versus Photon Radiation Therapy in Non-Small Cell Lung Cancer. Int J Radiat Oncol Biol Phys 2017; 97:128-137. [DOI: 10.1016/j.ijrobp.2016.10.001] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 09/22/2016] [Accepted: 10/03/2016] [Indexed: 12/25/2022]
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30
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Koyfman SA, Cooper JS, Beitler JJ, Busse PM, Jones CU, McDonald MW, Quon H, Ridge JA, Saba NF, Salama JK, Siddiqui F, Smith RV, Worden F, Yao M, Yom SS. ACR Appropriateness Criteria(®) Aggressive Nonmelanomatous Skin Cancer of the Head and Neck. Head Neck 2016; 38:175-82. [PMID: 26791005 DOI: 10.1002/hed.24171] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 06/11/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Aggressive nonmelanomatous skin cancer (NMSC) of the head and neck presents an increasingly common therapeutic challenge for which prospective clinical trials are lacking. METHODS The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. RESULTS The American College of Radiology Expert Panel on Radiation Oncology - Head and Neck Cancer developed consensus recommendations for guiding management of aggressive NMSC. CONCLUSION Multidisciplinary assessment is vital to guiding the ideal use of surgery, radiation, and systemic therapy in this disease.
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Affiliation(s)
| | | | | | - Paul M Busse
- Massachusetts General Hospital, Boston, Massachusetts
| | | | - Mark W McDonald
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Harry Quon
- Johns Hopkins University, Baltimore, Maryland
| | - John A Ridge
- Fox Chase Cancer Center, Philadelphia, Pennsylvania, American College of Surgeons
| | - Nabil F Saba
- Emory University, Atlanta, Georgia, American Society of Clinical Oncology
| | | | | | - Richard V Smith
- Montefiore Medical Center, Bronx, New York, American College of Surgeons
| | - Francis Worden
- University of Michigan, Ann Arbor, Michigan, American Society of Clinical Oncology
| | - Min Yao
- University Hospitals Case Medical Center, Cleveland, Ohio
| | - Sue S Yom
- University of California San Francisco, San Francisco, California
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31
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Schneider AL, Deig CR, Prasad KG, Nelson BG, Mantravadi AV, Brigance JS, Langer MP, McDonald MW, Johnstone PA, Moore MG. Ability of the National Surgical Quality Improvement Program Risk Calculator to Predict Complications Following Total Laryngectomy. JAMA Otolaryngol Head Neck Surg 2016; 142:972-979. [DOI: 10.1001/jamaoto.2016.1809] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Alexander L. Schneider
- Department of Otolaryngology–Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christopher R. Deig
- Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kumar G. Prasad
- Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Benton G. Nelson
- Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Avinash V. Mantravadi
- Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Joseph S. Brigance
- Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mark P. Langer
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mark W. McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia
| | | | - Michael G. Moore
- Department of Otolaryngology–Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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McDonald MW, Zolali-Meybodi O, Lehnert SJ, Estabrook NC, Liu Y, Cohen-Gadol AA, Moore MG. Reirradiation of Recurrent and Second Primary Head and Neck Cancer With Proton Therapy. Int J Radiat Oncol Biol Phys 2016; 96:808-819. [PMID: 27788954 DOI: 10.1016/j.ijrobp.2016.07.037] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 06/10/2016] [Accepted: 07/27/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE To report the clinical outcomes of head and neck reirradiation with proton therapy. METHODS AND MATERIALS From 2004 to 2014, 61 patients received curative-intent proton reirradiation, primarily for disease involving skull base structures, at a median of 23 months from the most recent previous course of radiation. Most had squamous cell (52.5%) or adenoid cystic (16.4%) carcinoma. Salvage surgery before reirradiation was undertaken in 47.5%. Gross residual disease was present in 70.5%. For patients with microscopic residual disease, the median dose of reirradiation was 66 Gy (relative biological effectiveness), and for gross disease was 70.2 Gy (relative biological effectiveness). Concurrent chemotherapy was given in 27.9%. RESULTS The median follow-up time was 15.2 months and was 28.7 months for patients remaining alive. The 2-year overall survival estimate was 32.7%, and the median overall survival was 16.5 months. The 2-year cumulative incidence of local failure with death as a competing risk was 19.7%; regional nodal failure, 3.3%; and distant metastases, 38.3%. On multivariable analysis, Karnofsky performance status ≤70%, the presence of a gastrostomy tube before reirradiation, and an increasing number of previous courses of radiation therapy were associated with a greater hazard ratio for death. A cutaneous primary tumor, gross residual disease, increasing gross tumor volume, and a lower radiation dose were associated with a greater hazard ratio for local failure. Grade ≥3 toxicities were seen in 14.7% acutely and 24.6% in the late setting, including 3 treatment-related deaths. CONCLUSIONS Reirradiation with proton therapy, with or without chemotherapy, provided reasonable locoregional disease control, toxicity profiles, and survival outcomes for an advanced-stage and heavily pretreated population. Additional data are needed to identify which patients are most likely to benefit from aggressive efforts to achieve local disease control and to evaluate the potential benefit of proton therapy relative to other modalities of reirradiation.
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Affiliation(s)
- Mark W McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, Atlanta, Georgia.
| | - Omid Zolali-Meybodi
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephen J Lehnert
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Neil C Estabrook
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Yuan Liu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health of Emory University, Atlanta, Georgia
| | - Aaron A Cohen-Gadol
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael G Moore
- Department of Otolaryngology-Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Estabrook NC, Hoene TA, Carlin PS, McDonald MW. Quantifying Proton Fields for Midline Brain Tumors: A Benefit/Cost Analysis of Planning Objectives. Int J Part Ther 2016; 3:13-20. [DOI: 10.14338/ijpt-15-00039.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 06/13/2016] [Indexed: 11/21/2022] Open
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McDonald MW, Liu Y, Moore MG, Johnstone PAS. Acute toxicity in comprehensive head and neck radiation for nasopharynx and paranasal sinus cancers: cohort comparison of 3D conformal proton therapy and intensity modulated radiation therapy. Radiat Oncol 2016; 11:32. [PMID: 26922239 PMCID: PMC4769827 DOI: 10.1186/s13014-016-0600-3] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 01/23/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND To evaluate acute toxicity endpoints in a cohort of patients receiving head and neck radiation with proton therapy or intensity modulated radiation therapy (IMRT). METHODS Forty patients received comprehensive head and neck radiation including bilateral cervical nodal radiation, given with or without chemotherapy, for tumors of the nasopharynx, nasal cavity or paranasal sinuses, any T stage, N0-2. Fourteen received comprehensive treatment with proton therapy, and 26 were treated with IMRT, either comprehensively or matched to proton therapy delivered to the primary tumor site. Toxicity endpoints assessed included g-tube dependence at the completion of radiation and at 3 months after radiation, opioid pain medication requirement compared to pretreatment normalized as equivalent morphine dose (EMD) at completion of treatment, and at 1 and 3 months after radiation. RESULTS In a multivariable model including confounding variables of concurrent chemotherapy and involved nodal disease, comprehensive head and neck radiation therapy using proton therapy was associated with a lower opioid pain requirement at the completion of radiation and a lower rate of gastrostomy tube dependence by the completion of radiation therapy and at 3 months after radiation compared to IMRT. Proton therapy was associated with statistically significant lower mean doses to the oral cavity, esophagus, larynx, and parotid glands. In subgroup analysis of 32 patients receiving concurrent chemotherapy, there was a statistically significant correlation with a greater opioid pain medication requirement at the completion of radiation and both increasing mean dose to the oral cavity and to the esophagus. CONCLUSIONS Proton therapy was associated with significantly reduced radiation dose to assessed non-target normal tissues and a reduced rate of gastrostomy tube dependence and opioid pain medication requirements. This warrants further evaluation in larger studies, ideally with patient-reported toxicity outcomes and quality of life endpoints.
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Affiliation(s)
- Mark W McDonald
- Department of Radiation Oncology, Winship Cancer Institute of Emory University, 1365 Clifton Rd NE Suite A1300, Atlanta, GA, 30322, USA.
| | - Yuan Liu
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health of Emory University, Atlanta, GA, USA.
| | - Michael G Moore
- Department of Otolaryngology/Head and Neck Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Peter A S Johnstone
- Department of Radiation Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA.
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Linton OR, Moore MG, Brigance JS, Summerlin DJ, McDonald MW. Proton therapy for head and neck adenoid cystic carcinoma: initial clinical outcomes. Head Neck 2015; 37:117-24. [PMID: 25646551 DOI: 10.1002/hed.23573] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The purpose of this study was to report outcomes of proton therapy in head and neck adenoid cystic carcinoma. METHODS We conducted a retrospective analysis of 26 patients treated between 2004 and 2012. Twenty patients (77%) had base of skull involvement; 19 (73%) were treated for initial disease and 7 (27%) for recurrent disease. Twenty patients were treated postoperatively, 6 after biopsy alone and 24 had positive margins or gross residual disease.Median dose delivered was 72 Gy (relative biological effectiveness[RBE]). RESULTS Median follow-up was 25 months (range, 7–50 months). The 2-year overall survival was 93% for initial disease course and 57% for recurrent disease (p5.19). The 2-year local control was 95% for initial disease and 86% for recurrent disease (p5.48). The 2-year distant metastatic rate was 25%. Late toxicity of grade 0 or 1 was seen in 17 patients, grade 2 in 5, grade 3 in 2, grade 4 in 1, and grade 5 in 1. CONCLUSION Initial outcomes of proton therapy are encouraging. Longer follow-up is required.
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Jia Y, Zhao L, Cheng CW, McDonald MW, Das IJ. Dose perturbation effect of metallic spinal implants in proton beam therapy. J Appl Clin Med Phys 2015; 16:333-343. [PMID: 26699317 PMCID: PMC5690149 DOI: 10.1120/jacmp.v16i5.5566] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 05/09/2015] [Accepted: 05/01/2015] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study was to investigate the effect of dose perturbations for two metallic spinal screw implants in proton beam therapy in the perpendicular and parallel beam geometry. A 5.5 mm (diameter) by 45 mm (length) stainless steel (SS) screw and a 5.5 mm by 35 mm titanium (Ti) screw commonly used for spinal fixation were CT‐scanned in a hybrid phantom of water and solid water. The CT data were processed with an orthopedic metal artifact reduction (O‐MAR) algorithm. Treatment plans were generated for each metal screw with a proton beam oriented, first parallel and then perpendicular, to the longitudinal axis of the screw. The calculated dose profiles were compared with measured results from a plane‐parallel ion chamber and Gafchromic EBT2 films. For the perpendicular setup, the measured dose immediately downstream from the screw exhibited dose enhancement up to 12% for SS and 8% for Ti, respectively, but such dose perturbation was not observed outside the lateral edges of the screws. The TPS showed 5% and 2% dose reductions immediately at the interface for the SS and Ti screws, respectively, and up to 9% dose enhancements within 1 cm outside of the lateral edges of the screws. The measured dose enhancement was only observed within 5 mm from the interface along the beam path. At deeper depths, the lateral dose profiles appeared to be similar between the measurement and TPS, with dose reduction in the screw shadow region and dose enhancement within 1–2 cm outside of the lateral edges of the metals. For the parallel setup, no significant dose perturbation was detected at lateral distance beyond 3 mm away from both screws. Significant dose discrepancies exist between TPS calculations and ion chamber and film measurements in close proximity of high‐Z inhomogeneities. The observed dose enhancement effect with proton therapy is not correctly modeled by TPS. An extra measure of caution should be taken when evaluating dosimetry with spinal metallic implants. PACS number: 87.50.sj
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Affiliation(s)
- Yingcui Jia
- Indiana University School of Medicine;University Health Proton Therapy Center.
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McDonald MW, Walter AS, Hoene TA. Technique for comprehensive head and neck irradiation using 3-dimensional conformal proton therapy. Med Dosim 2015; 40:333-9. [PMID: 26002120 DOI: 10.1016/j.meddos.2015.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 02/18/2015] [Accepted: 04/12/2015] [Indexed: 10/23/2022]
Abstract
Owing to the technical and logistical complexities of matching photon and proton treatment modalities, we developed and implemented a technique of comprehensive head and neck radiation using 3-dimensional (3D) conformal proton therapy. A monoisocentric technique was used with a 30-cm snout. Cervical lymphatics were treated with 3 fields: a posterior-anterior field with a midline block and a right and a left posterior oblique field. The matchline of the 3 cervical nodal fields with the primary tumor site fields was staggered by 0.5cm. Comparative intensity-modulated photon plans were later developed for 12 previously treated patients to provide equivalent target coverage, while matching or improving on the proton plans׳ sparing of organs at risk (OARs). Dosimetry to OARs was evaluated and compared by treatment modality. Comprehensive head and neck irradiation using proton therapy yielded treatment plans with significant dose avoidance of the oral cavity and midline neck structures. When compared with the generated intensity-modulated radiation therapy (IMRT) plans, the proton treatment plans yielded statistically significant reductions in the mean and integral radiation dose to the oral cavity, larynx, esophagus, and the maximally spared parotid gland. There was no significant difference in mean dose to the lesser-spared parotid gland by treatment modality or in mean or integral dose to the spared submandibular glands. A technique for cervical nodal irradiation using 3D conformal proton therapy with uniform scanning was developed and clinically implemented. Use of proton therapy for cervical nodal irradiation resulted in large volume of dose avoidance to the oral cavity and low dose exposure to midline structures of the larynx and the esophagus, with lower mean and integral dose to assessed OARs when compared with competing IMRT plans.
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Affiliation(s)
- Mark W McDonald
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN; Indiana University Health Proton Therapy Center, Bloomington, IN.
| | - Alexander S Walter
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN
| | - Ted A Hoene
- Indiana University Health Proton Therapy Center, Bloomington, IN
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Estabrook NC, McDonald MW, Hoene TA, Bartlett GK, Johnstone PA, McMullen KP, Buchsbaum JC. Proton Radiotherapy for Midline Central Nervous System Lesions: A Class Solution. Oncology 2015; 89:111-7. [DOI: 10.1159/000377727] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 02/05/2015] [Indexed: 11/19/2022]
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McDonald MW, Linton OR, Shah MV. Proton therapy for reirradiation of progressive or recurrent chordoma. Int J Radiat Oncol Biol Phys 2014; 87:1107-14. [PMID: 24267972 DOI: 10.1016/j.ijrobp.2013.09.038] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 09/11/2013] [Accepted: 09/19/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE To report the results in patients reirradiated with proton therapy for recurrent or progressive chordoma, with or without salvage surgery. METHODS AND MATERIALS A retrospective review of 16 consecutive patients treated from 2005 to 2012 was performed. All patients had received at least 1 prior course of radiation therapy to the same area, and all but 1 patient had at least 1 surgical resection for disease before receiving reirradiation. At the time of recurrence or progression, half of the patients underwent additional salvage surgery before receiving reirradiation. The median prior dose of radiation was 75.2 Gy (range, 40-79.2 Gy). Six patients had received prior proton therapy, and the remainder had received photon radiation. The median gross tumor volume at the time of reirradiation was 71 cm(3) (range, 0-701 cm(3)). Reirradiation occurred at a median interval of 37 months after prior radiation (range, 12-129 months), and the median dose of reirradiation was 75.6 Gy (relative biological effectiveness [RBE]) (range. 71.2-79.2 Gy [RBE]), given in standard daily fractionation (n=14) or hyperfractionation (n=2). RESULTS The median follow-up time was 23 months (range, 6-63 months); it was 26 months in patients alive at the last follow-up visit (range, 12-63 months). The 2-year estimate for local control was 85%, overall survival 80%, chordoma-specific survival 88%, and development of distant metastases 20%. Four patients have had local progression: 3 in-field and 1 marginal. Late toxicity included grade 3 bitemporal lobe radionecrosis in 1 patient that improved with hyperbaric oxygen, a grade 4 cerebrospinal fluid leak with meningitis in 1 patient, and a grade 4 ischemic brainstem stroke (out of radiation field) in 1 patient, with subsequent neurologic recovery. CONCLUSIONS Full-dose proton reirradiation provided encouraging initial disease control and overall survival for patients with recurrent or progressive chordoma, although additional toxicities may develop with longer follow-up times.
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Affiliation(s)
- Mark W McDonald
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, Indiana; Indiana University Health Proton Therapy Center, Bloomington, Indiana.
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Buchsbaum JC, McDonald MW, Johnstone PAS, Hoene T, Mendonca M, Cheng CW, Das IJ, McMullen KP, Wolanski MR. Range modulation in proton therapy planning: a simple method for mitigating effects of increased relative biological effectiveness at the end-of-range of clinical proton beams. Radiat Oncol 2014; 9:2. [PMID: 24383792 PMCID: PMC3904459 DOI: 10.1186/1748-717x-9-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 12/23/2013] [Indexed: 01/28/2023] Open
Abstract
Background The increase in relative biological effectiveness (RBE) of proton beams at the distal edge of the spread out Bragg peak (SOBP) is a well-known phenomenon that is difficult to quantify accurately in vivo. For purposes of treatment planning, disallowing the distal SOBP to fall within vulnerable tissues hampers sparing to the extent possible with proton beam therapy (PBT). We propose the distal RBE uncertainty may be straightforwardly mitigated with a technique we call “range modulation”. With range modulation, the distal falloff is smeared, reducing both the dose and average RBE over the terminal few millimeters of the SOBP. Methods One patient plan was selected to serve as an example for direct comparison of image-guided radiotherapy plans using non-range modulation PBT (NRMPBT), and range-modulation PBT (RMPBT). An additional plan using RMPBT was created to represent a re-treatment scenario (RMPBTrt) using a vertex beam. Planning statistics regarding dose, volume of the planning targets, and color images of the plans are shown. Results The three plans generated for this patient reveal that in all cases dosimetric and device manufacturing advantages are able to be achieved using RMPBT. Organ at risk (OAR) doses to critical structures such as the cochleae, optic apparatus, hypothalamus, and temporal lobes can be selectively spared using this method. Concerns about the location of the RBE that did significantly impact beam selection and treatment planning no longer have the same impact on the process, allowing these structures to be spared dose and subsequent associated issues. Conclusions This present study has illustrated that RMPBT can improve OAR sparing while giving equivalent coverage to target volumes relative to traditional PBT methods while avoiding the increased RBE at the end of the beam. It has proven easy to design and implement and robust in our planning process. The method underscores the need to optimize treatment plans in PBT for both traditional energy dose in gray (Gy) and biologic dose (RBE).
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Affiliation(s)
- Jeffrey C Buchsbaum
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA.
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Linton OR, Moore MG, Brigance JS, Gordon CA, Summerlin DJ, McDonald MW. Prognostic Significance of Basaloid Squamous Cell Carcinoma in Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2013; 139:1306-11. [DOI: 10.1001/jamaoto.2013.5308] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Okechukwu R. Linton
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis
| | - Michael G. Moore
- Department of Otolaryngology/Head & Neck Surgery, Indiana University School of Medicine, Indianapolis
| | - Joseph S. Brigance
- Department of Otolaryngology/Head & Neck Surgery, Indiana University School of Medicine, Indianapolis
| | - Chris A. Gordon
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis
| | - Don-John Summerlin
- Department of Pathology, Indiana University School of Medicine, Indianapolis
| | - Mark W. McDonald
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis4Indiana University Health Proton Therapy Center, Bloomington
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Ridge JA, Lawson J, Yom SS, Garg MK, McDonald MW, Quon H, Saba N, Salama JK, Smith RV, Worden F, Yeung AR, Beitler JJ. American college of radiology appropriateness criteria®treatment of stage I T1 glottic cancer. Head Neck 2013; 36:3-8. [DOI: 10.1002/hed.23381] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 05/01/2013] [Indexed: 11/11/2022] Open
Affiliation(s)
- John A. Ridge
- Fox Chase Cancer Center; (American College of Surgeons); Philadelphia Pennsylvania
| | - Joshua Lawson
- University of California San Diego; La Jolla California
| | - Sue S. Yom
- University of California San Francisco; San Francisco California
| | | | | | - Harry Quon
- University of Pennsylvania; Philadelphia Pennsylvania
| | - Nabil Saba
- Emory University; (American Society of Clinical Oncology); Atlanta Georgia
| | | | - Richard V. Smith
- Montefiore Medical Center; American College of Surgeons; Bronx New York
| | - Francis Worden
- University of Michigan; (American Society of Clinical Oncology); Ann Arbor Michigan
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Garg MK, Ridge JA, Yom SS, McDonald MW, Quon H, Smith RV, Yeung AR, Lawson J, Saba N, Salama JK, Beitler JJ. Reply, contralateral irradiation for T(limited)N2bM0 lateralized tonsil cancer. Head Neck 2013; 35:465-6. [PMID: 23386559 DOI: 10.1002/hed.23212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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McDonald MW, Wolanski MR, Simmons JW, Buchsbaum JC. Technique for sparing previously irradiated critical normal structures in salvage proton craniospinal irradiation. Radiat Oncol 2013; 8:14. [PMID: 23311343 PMCID: PMC3556160 DOI: 10.1186/1748-717x-8-14] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 12/27/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cranial reirradiation is clinically appropriate in some cases but cumulative radiation dose to critical normal structures remains a practical concern. The authors developed a simple technique in 3D conformal proton craniospinal irradiation (CSI) to block organs at risk (OAR) while minimizing underdosing of adjacent target brain tissue. METHODS Two clinical cases illustrate the use of proton therapy to provide salvage CSI when a previously irradiated OAR required sparing from additional radiation dose. The prior radiation plan was coregistered to the treatment planning CT to create a planning organ at risk volume (PRV) around the OAR. Right and left lateral cranial whole brain proton apertures were created with a small block over the PRV. Then right and left lateral "inverse apertures" were generated, creating an aperture opening in the shape of the area previously blocked and blocking the area previously open. The inverse aperture opening was made one millimeter smaller than the original block to minimize the risk of dose overlap. The inverse apertures were used to irradiate the target volume lateral to the PRV, selecting a proton beam range to abut the 50% isodose line against either lateral edge of the PRV. Together, the 4 cranial proton fields created a region of complete dose avoidance around the OAR. Comparative photon treatment plans were generated with opposed lateral X-ray fields with custom blocks and coplanar intensity modulated radiation therapy optimized to avoid the PRV. Cumulative dose volume histograms were evaluated. RESULTS Treatment plans were developed and successfully implemented to provide sparing of previously irradiated critical normal structures while treating target brain lateral to these structures. The absence of dose overlapping during irradiation through the inverse apertures was confirmed by film. Compared to the lateral X-ray and IMRT treatment plans, the proton CSI technique improved coverage of target brain tissue while providing the least additional radiation dose to the previously irradiated OAR. CONCLUSIONS Proton craniospinal irradiation can be adapted to provide complete sparing of previously irradiated OARs. This technique may extend the option of reirradiation to patients otherwise deemed ineligible for further radiotherapy due to prior dose to critical normal structures.
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Affiliation(s)
- Mark W McDonald
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN, USA.
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Eaton BR, McDonald MW, Kim S, Marcus RB, Sutter AL, Chen Z, Esiashvili N. Radiation therapy target volume reduction in pediatric rhabdomyosarcoma. Cancer 2012; 119:1578-85. [DOI: 10.1002/cncr.27934] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 11/02/2012] [Accepted: 11/06/2012] [Indexed: 11/10/2022]
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McDonald MW, Lawson J, Yom SS, Garg MK, Quon H, Ridge JA, Saba NF, Salama JK, Smith RV, Yeung AR, Beitler JJ. American College of Radiology Appropriateness Criteria on Retreatment of Recurrent Head-and-Neck Cancer After Prior Definitive Radiation. Int J Radiat Oncol Biol Phys 2012. [DOI: 10.1016/j.ijrobp.2011.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Yeung AR, Garg MK, Lawson J, McDonald MW, Quon H, Ridge JA, Saba N, Salama JK, Smith RV, Yom SS, Beitler JJ. ACR appropriateness criteria® ipsilateral radiation for squamous cell carcinoma of the tonsil. Head Neck 2012; 34:613-6. [DOI: 10.1002/hed.21993] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2011] [Indexed: 11/06/2022] Open
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